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F . <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone': (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 17- <br /> T <br /> 7 <br /> . i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED` Date Issued 7 <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 HealthrDistrict. <br /> JOB ADDRESS/LOCATION .1Y, GCl _.� J E ;US TRACT j <br /> Owner's Name _...__._� Phone <br /> Address <br /> Contractor's Name License #l( X373 Phone30j <br /> i� <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/ / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION fi;�' PUMP REPAIR/ / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK jrSEWER 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 J6 " <br /> 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 . y_ Rotary Type of Grout <br /> Disposal, Other Other Information ' <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: <br /> Contractor <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 <br /> Describe Material and Procedure <br /> I <br /> I hereby agree to comply.with all laws and regulations of theSan 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 DRILLERS REPORT of the well and notify them before putting the..well in use. The above <br /> information is true to the bestof m ..knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO N AND F AL INSPE ION. <br /> SIGNED TITLE <br /> W..PL''T PLAN ON REVERSE SIDE) I, ` <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED Bf DATE <br /> ADDITIONAL COMMENTS: _ <br /> PHASE II GROUT INSPE`CTZON PHASE,,,IZI/FIXAL INSPECTION <br /> INSPECTION BY DATE INSPECTION DATE 411-1 <br /> E H 1426, Rev. 1-Tj 3/76 2M i <br />