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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> r t Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7,f-/41;V0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /.)-- 7-7r <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 CENSUS TRACT ' <br /> Owner's Name Phone <br /> - a <br /> Address City <br /> r <br /> Contractor's Name License # hone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/ / RECONDITION / / DESTRUCTION /- <br /> PUMP-INSTAL TION / / PUMP REPAIR / / PUMP REPLACEMENT 1-T ¢ s <br /> Other l <br /> DISTANCE TO NEAREST: SEPTIC TANK / h 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 f <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing .. <br /> Domestic/public Driven Gauge of Casing 09 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection p<, : _.RotaryType of, Grout <br /> Disposal Other Other Information.' <br /> Geophysical ; Surface Seal Installed B e <br /> x <br /> PUMP INSTALLATION: Contractor i <br /> Type of Pump ... F H.P. <br /> PUMP REPLACEMENT: / / S tate .Work Done <br /> PUMP .REPAIR: " / /� State Work Done��� <br /> DES-TRUCTION OF WELL: kWell Diameter Approximate Depth <br /> . r Describe Material and Procedure <br /> 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 a <br /> WELL'DRI'LLERS REPORT-of.-the well and-notify them before putting the well in use. The above <br /> information is true to the be t ofVmy.k wledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR- TO UTI AND F N IN ECT <br /> SIGNED ' i TITLE <br /> D Ph T' PLAN 'ON REVER SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I _ <br /> APPLICATION ACCEPTED BY 0111- <br /> DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> 'INSPECTION BY [ - DATE /1- /� INSPECTION BY (' . �,_ DATE <br /> 3/76 2M <br /> E-H 1426 Rev. 1--74 } <br />