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- ----- � SAN JOAQUIN LOCAL HEALTH DISTRICT <br />' FOF OFFICE USE 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209)' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 7_//�'� <br /> 0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued ��7 � <br /> (Complete In Triplicate.) <br /> Application 'is' Aereby made to the San Joaquin Local Health District for a permit to construct' <br /> and/or install the work herein described. <br /> This application is made in compliance with San J(?aquin ; <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address <br /> _ city , <br /> Contractor's Name License phone _-q p <br /> TYPE OF WORK (Check) : NEW WELL' /_7 DEEPEN / RECONDITION /7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other /7/ <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 1 Cable Tool Dia, of <br /> Domestic/private Well Excavation <br /> Domestic/publDrilled Dia. of Well Casing i <br /> ic � <br /> 1 Driven Gauge of Casing t <br /> Irrigation 1 Gravel Pack " De'pth of Grout Seal <br /> Cathodic Protectioni1 Rotary Typeof Grout i <br />' Disposal 1 Other Other 'Information <br /> Geophysical -Surf ace-Seal�°Installed Byr - - ..-- <br />?UMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br />'UMP REPLACEMENT: State Work Done <br />'UMP .REPAIR: <br /> State Work Done �� �- �- �tc <br /> f-S,TRUCTION OF WELL: Well Diameter <br /> Describe Material arid Procedure Approximate Depth <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> end the State of California pertaining to or regulating well "construction. Within FIFTEEN DAYS <br /> fter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> TELL DRILLERS REPORT of the well and notifythem before <br /> putting the well in use. The above j <br /> nformation is true to the bestlof my knowledge and belief. I WILL CALL FOR A GROUT INSPECT <br /> RIOR TO GROUTING AND A FINAL IN E ION <br /> ON. ' <br /> IGNED TITLE <br /> (D W PLOT PLAN ON REVERSE-SIDE) f <br /> RASE I <br /> A I FOR DEPARTMENT USE ONLY <br /> t <br /> PPLICATION ACCEPTED BY DATE <br /> PHASE <br /> D.DITIONAL COMMENTS: - -- - ' <br /> PHASE II GROUT INSPECTION PHALSE /lI INSPECTION <br /> NSPECTION BY DATE INSPECTION $ DATE _ <br /> 1 <br /> .E H 1426 Rev. 1-74 1/?7 , 2M 1 <br /> . <br />