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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. -71_4)� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3 3 <br /> E (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. 18.62 and the Rule's and Regulations of the San Joaquin Local Health District. <br /> t <br /> E JOB ADDRESS/LOCATION.;/ CENSUS TRACT <br /> Owner's Name r Phone <br /> Address `# v <br /> City . <br /> Contractor's Name f ? <br /> License <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR /—/ 7T— <br /> Other.: <br /> / PUMP REPLACEMENT /_7 <br /> O they 1/7 <br /> DISTANCE TO NEAREST: SEPTIC TANK_Vj- SEWER LINE511 PIT PRIVY —� <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT � OTHER 4 <br /> PROPERTY LINE <br /> PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ! Cable Tool Dia, of Well Excavation S <br /> Domestic/private _iDrilled Dia. of Well, Casing <br /> Domestic/public t Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection t k Rotary Type of Grout <br /> Disposal 1 I " Other <br /> Other Information <br /> Geophysical -� Surface Seal Installed B <br /> PUMP INSTALLATION'" Contractor <br /> Type of Pump H.P, . <br /> PUMP REPLACEMENT; / / State Work Done <br /> PUMP 'REPAIR: / / S ate Work Done <br /> t 4 <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describie Material and Procedure p <br /> I hereby agree to comply with all laws and regulations of the Sari Joaquin Local Health District <br /> and the State of California pertaining to or regulating well 'con.struction. 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.. <br /> information is true to the best of- my knowledge and belief. I WILL CALL FOR A GROUT eINSPECTION <br /> PRIOR TO GROUTING above <br /> D A �IN �INECTION. <br /> SIGNED t <br /> TITLE Lfflr i <br /> (DRAW PLOT PLAN ON REVERSE SI <br /> j <br /> PHASE T FOR DEPARTMENT USE ONLY <br /> f <br /> APPLICATION ACCEPTED BY r <br /> DATE <br /> ADDITIONAL COMMENTS: . <br /> PHAS II GROUT INSPECTIO PHAS III/FINAL INSPECTION <br /> INSPECTION BY DATE 8 INSPECTION BY ` .. DATE 3 <br /> E H 1426 Rev. , 1-74 6777 <br />