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SAN JOAQUIN LOCAL .HEALTH DISTRICT <br /> FORrOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> ' Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7 �J <br /> THIS PERMIT EXPIRES 1• YEAR FROM.DATE ISSUED Date Issued .. 7� <br /> . (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local 'Realth 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 /> JOB ADDRESS/LOCATION 1r�y CENSUS TRACT <br /> Owner's Name pm P.,tPhone j <br /> Address - City �0'�! <br /> i.f o�l►° ff <br /> � . <br /> Contractor's Name + License # / honed-7� <br /> TYPE OF WORK (Check): NEW WELL/_T DEEPEN -/—/ RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR 4X7 PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY a <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 I Rotary Type of Grout <br /> z Disposal Other Other Information <br /> Geophysical .'i Surface Seal Installed By: <br /> PUMP -INSTALLATION: <br /> Contractor <br /> Type of Pump AIS A0H.P. <br /> PUMP REPLACEMENT: /_7 State Work Done j <br /> PUMP ..REPAIR: /37 State Work Done <br /> 11 i <br /> ES•TRUCTION OF WELL: Well Diameter Approximate 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 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 befoie putting the..well in-use.. The above <br /> information is true to the-best of my knowledge and.:_h lief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO 94RQRTING AND A FINAL INSP <br /> SIGNED <br /> _ LE �. <br /> (DRAW LO ON REV SE SID—El., <br /> F EPARTMENT USE, ONLY <br /> PHASE I - <br /> APPLICATION ACCEPTED Y4'L TDATE / <br /> ADDITIONAL COMMENTS: 1 <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY 8 DATE !i <br /> E H 1426 Rev. 1-74 1-74 2M <br />