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�. .+ JOAQUIN LOCAL HEALTH DISTRIC'1 y <br /> .FOF,rOFFICE USE: 1601. E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 711-114;581v� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7V- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct: <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION g 7 CENSUS TRACT <br /> Owner's Name Phone 7 <br /> i <br /> Address z O '7 �, City <br /> Contractor's Name License 0P Phone -O�a <br /> t <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN /-7 RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTALLATION / PUMP REPAIR /-7 PUMP REPLACEMENT /-7 <br /> Other / 7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE '- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONSj_,� <br /> Industrial Cable Tool -Dia. of---Well Excavation b <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driver: Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal. <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type Of Pump H.P. ` r <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP'REPAIR: L7 State Work DonePESi <br /> TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District r <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a' <br /> WELL DRILLERS REPORT of the well and notify them before putting the-well. in use.. The above <br /> information is true to the-best of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY %` DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION HA5E III F INAL INSPECTION <br /> INSPECTION BY �—� DATE .r :• INSPECTION BY DATE <br />�1 € ' E H 1426 Rev. 1-74 ��f•�,� �„ <br />