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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. :27- <br /> THIS <br /> 7THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 2_1-3- ,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. 1 <br /> /j 9a 62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> r .14 <br /> APA DDRESS/LOCATN Gt1 CENSUS TRACT <br /> Owner's Name Phone3( ' <br /> Address City ' <br /> Contractor's Name 4DLicense #14.)J73 Phone-?( <br /> i <br /> TYPE OF WORK (Check) : NEW WELL /% DEEPEN/% RECONDITION [—/ DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR A/ PUMP REPLACEMEN-T /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 H.P. _ <br /> PUMP REPLACEMENT: 1_7 State Work Done <br /> PUMP .REPAIR: )>/--- State Work Done ` <br /> DESTRUCTION OF WELL: Well DiameterApproximate 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 comp'letiaft-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 rue to the be of- my..knawl ge and belief, i WILL CALL FOR A GROUT INSP CT ION <br /> PRIOR TO GROU G D A F INSPECTION <br /> SIGNED TITLE <br /> nX DRAW PL'T PLAN ON REV ERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �� <br /> APPLICATION ACCEPTED BY DATE -7-11-' <br /> ADDITIONAL <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY /OCL DATE <br /> E H �- _ - _ <br /> 1426 REv.�l--74 __ 3/75 2M <br /> .. : <br />