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0" <br /> _ SAN JOAQUIN LOCAL HEALTH DISTRICT � <br /> FOR„O,F�FIC� USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> l w <br /> t Telephone : (2090 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. '—Ae(:i V- <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued./,1-/­7,7 <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 Health District. <br /> JOB ADDRESS/LOCATION.- . . CENSUS TRACT <br /> Owner's Name Phone <br /> Address c . City <br /> Contractor's NameS - License ��o� Phone' -3d. <br /> TYPE OF WORK (Check) : NEW WELL /Z�- DEEPEN '/ / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK ��f-t SEWER LINES 7(/� y PIT PRIVY <br /> SEWAGE DISPOSAL FIELD - r CESSPOOL/SEEPAGE­PIT - - ----OTHER <br /> PROPERTY; LINE 4 PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial —S� Cable Tool Dia, of Well Excavation <br /> Domestic/private + Drilled Dia, of Well Casing _ 6 / <br /> Domestic/public a Driven Gauge of Casing <br /> Irrigation i Gravel Pack Depth of Grout Seal sp i <br /> Cathodic Protection 1 Rotary Type of Grout ���►��v T1 <br /> Disposal t Other - Other Information . <br /> Geophysical TSuFf ace_Seal Ins talled 1 : Wa 5 i _ <br /> PUMP INSTALLATION: Contractor <br /> Type ofl Pump H.P. <br /> i <br /> PUMP REPLACEMENT: / / State Work Done _ <br /> PUMP .REPAIR: / / State Work Done r <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 we11,-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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE � . <br /> {DRAW PLOT PLAN ON REVERSE SID ) ' <br /> FOR DEPARTMENT USE ONLY F ; <br /> PHASE I t <br /> APPLICATION ACCEPTED BY DATE 19-7-2) <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II /FINAL INSPECTION <br /> INSPECTION BY 7- DATE J�. . �� INSPECTION BY DATE <br /> ......._.__ .�..___._ Gam[ <br />�*: H 1426 Rev. - 1-74' <br /> ev. • 1-74 cif 77 _ 21 <br />