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SAN JOAQUIN LOCAL HEALTH DISTRICT L ! <br /> fY� <br /> FOE OF'FICE'USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> t rIf f-"��- <br /> (Complete In Triplicate)c f t.r +'S { p P <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 /> i <br /> JOB ADDRESS/LOCATIONCENSUS TRACT <br /> Owner's Name Phone <br /> Address Its (� City <br /> Contractor's Name � y _ License Phone3f. <br /> i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other & V 17 <br /> — 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> -_._SEWAGE...D.ISPOSAL..F.IELD-_- . .___..CESSPOOL/SEEPAGE__PIT _OTHER <br /> PROPERTY LINE -� PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL h <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable-Tool-- .. Dia. of Well Excavation y <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 ,.:. Rotary Typeof Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMPmINSTALLATION: ' Contractor <br /> 'Type- ofH.P <br /> . Pump .� - �, <br /> PUMP REPLACEMENT: /. / State Work -Done <br /> PUMP REPAIR: / / .,State Work Done <br /> DES-TRUCTION OF WELL: Well Diameter - t�. Approximate Depth <br /> Describe Material Ajid Procedure Xv SP <br /> I hereby agree to comply witIf all law's and regulations of fhe 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 GROUTIboilij A FI INSPE ON. <br /> SIGNED TITLE <br /> W PL T PLAN ON RE FRSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .BY DATE. <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIO �- PHASE III/ INAL INSPECT ON <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 376 2M <br />