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. 4 <br /> SAN JOAQUIN LOCAL. HEALTH DISTRICT � <br /> FOE OFFICE USE: 1601 E. HaSelton A-&. , ,Stockton, Calif. <br /> Telephone. (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 4 <br /> (Complete In Triplicate) <br /> Application is $ereby 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 $ule and R gulations of the San Joaquin Local Health District. <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> Owner's Name l (1 Phone <br /> Address zoCity <br /> ! <br /> , License # �- Phone S= <br /> Contractor s Name 3 <br /> TYPE OF WORK (Check) : NEW WELL I� DEEPEN / / RECONDITION / DESTRUCTION — <br /> PUMP INSTALLATION / / PUMP REPAIR/ / Pump REPLACEMENT <br /> I T <br /> Other /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 1;(,0 '^ 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 SPECIFICATIONSIN <br /> Industrial Cable Tool Dia. of Well Excavation 7`' (� <br /> Domestic/private r - ,Drilled Dia. of Well Casing ' <br /> L Domestic/public o 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 /> Geophysical ' Surface Seal Installed By: / .� <br /> S <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> .PUMP REPLACEMENT: / / State Work Done <br /> LUMP -.REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diamet r Approximate Depth <br /> Describe Material and Procedure > <br /> herebya 1 with all laws and regulations of the San Joaquin Local Health District <br /> tagree to comply P <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 /> inf oration 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. F <br /> - <br /> SIGNED �� - � .� a r� � V .) TITLE <br /> h � <br /> (DRAW-PLOT PLAN ON REV SE SID <br /> R DEP TMENT USE ONLY <br /> ° PHASE I DATE <br /> APPLICATION ACCEPTED BY77L <br /> ADDITIONAL COMMENTS: <br /> PHASE I UT INSPECTION y PRASE III/FINAL INSPECTION <br /> INSPECTION BY DA E INSPECTION BY DATE <br /> r_ f � <br /> E H 142b Rev. 1-74 <br />