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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F_0 .,OFFICB USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7,S-4 7D)6 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 2-» <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 /> loo S.I/J rick T <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Y Phone <br /> Address / Cc. City <br /> Contractor's Name �� . License #494 7?., phone <br /> TYPE OF WORK (Check) : NEW WELL -/_7 DEEPEN '/_' RECONDITION %T DESTRUCTION /-7 <br /> PUMP INSTALLATION gI PUMP REPAIR/7 PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER 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 <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 Type of Grout <br /> Disposal Other Other Information <br /> Geophysical. Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump LA ZL4 / H.P. <br /> PUMP REPLACEMENT I / State Work Done <br /> PUMP :: / State Work Done 4 <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure C <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,af m .. owl ge-and-b lief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO 0 TING AND A FINAL INSPECT <br /> SIGNE LE <br /> r ��. <br /> PLOT LAN ON REV SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY X DATE , 7 � <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P S FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE -S-75 <br /> E H 1426 Rev. 1-74 4/3-5 M <br />