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AV SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: 1601 E.-Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 / <br /> APPLICATION FOR WELT, CONSTRUCTION OR PUMP PERMIT Permit No. 7 S Z it/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued X—),2-7 <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 worm 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. r <br /> JOB ADDRESS/LOCATION r CENSUS TRACT <br /> Owner's NamePhone <br /> Address City .- <br /> Contractor's Name FLicense # Phone ILI hS�7 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/ 7 RECONDITION /7 DESTRUCTION /_ <br /> PUMP INS ALLATION / / PUMP REPAIR '/_7_PUMP REPLACEMENT <br /> Other /% <br /> • � i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPO AL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELT,' PUBLIC DOMESTIC WELL-- <br /> IN ENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONSi <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> !'''bomestic/public Driven Gauge of Casing / 7 <br /> Irrigation <br /> g `T Gravel Pack Depth of Grout Seal <br /> Cathodic Protection X- Rotary Type of Grout <br /> --t—Disposal Other Other Information <br /> Geophysical Surface Seal Installed 'B <br /> r <br /> PUMP It"STALLATION: 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 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 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 A105UTINGAN N INSPE ON. _ <br /> SIGNED TITLE . <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY el DATE / <br /> ADDITIONAL COMMENTS: <br /> P E IjE SPECTI PHASE-111 F&AL.,INSPECTION <br /> INSPECTION BY DATE 7= INSPECTION BY/' ,/°' DATE <br /> E H 1426 • Rev. .1-74 4/75 2m <br />