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/e,�/ SAN JOAQUIN LVCAL HEALTH DISTRICT <br /> FOE OFFICE USE: O: _ . Hazelton Ave. , Stockton, Cal <br /> v Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7,6_//a 9,e <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued //_ _7�z <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 gulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION a '�3 r / ! _ CENSUS TRACT <br /> Owner's Name �r / Phone <br /> Address 3CK J j City <br /> Contractor's Name <br /> 11 License Phone �11e �✓��� <br /> TYPE OF WORK (Check) : NEW WELL /_7 DEEPEN /_7 RECONDITION /—/ DESTRUCTION /_7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / <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 SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> _ CK Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> GeophysicalSurface 5eal Installed By: <br /> L <br /> PUMP INSTALLATION: Contractor 2 , ) <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done - <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth V <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> aad 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 /> W-LL 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 GROU G AND A FINAL NSPECTI N. <br /> SIGNED ��A2 ��b � TITLE <br /> DRAW-PLOT PLAN ON REVERSE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHAS II GROUT INSPECTION PHA III ,FINAL INSPECT N <br /> INSPECTION BY DATE INSPECTION BY / DATE / r <br /> E H 1426 Rev. 1-74 3/76 2H <br />