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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> 0TP OFFICE USE: .1601 E. Hazelton Avd. , S_ ockton, Calif. <br /> Telephone: 466-6781 `� _ yr/ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 T")--S S <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date=Issued L 7-751 <br /> (Complete In Triplicate) f;'` <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 CENSUS TRACT <br /> Owner's Name Phone —.. 1 <br /> Address City <br /> Contractor's -Name License Phone <br /> TYPE OF WORK (Check): NEW WELL/ : DEEPEN /_-7 RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INST ELATION / / PUMP REPAIR /-7 PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES : PIT PRIVY <br /> 'SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> r ,PROPERTY LINE -• PRIVATE DOMESTIC WELL iPUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial. Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> mestic/ ublic:` Driven Gauge of Casing " ` { <br /> .. <br /> rri atio `"Gravel Pack .'Depth of Grout Seal r <br />' Cat odic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical _ ace Seal Installed_ By: <br /> hysical Surf, <br /> PUMP 'INSTALLATION: Contractor r , _ •::I <br /> Type- of Pump H.P. <br /> :- <br /> PUMP REPLACEMENT: / J State'Work Done • <br /> PUMP .REPAIR: / / State Work Done . <br /> ES;TRUCTION OF WELL: Well Diameter Approximate Depth .. <br /> j Describe Material and Procedure <br /> k I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <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 ai <br /> WELL DRILLERS REPORT of the well and notify thea 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 GROUT G AN 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 . S <br /> E ADDITIONAL COMMENTS: <br />` PHASE II GROUT INSPECTION PHASE I I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY :DATE <br /> �� / <br /> )-E H 1426 Rev. 1-74 f-�9 [' /�'� 1-74 2M <br />