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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0F OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephdne: (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 27 107 yp <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued. 8:/s <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 /> JOB ADDRESS/LOCATI N Gy,/a-c d�c �. CENSUS TRACT <br /> F <br /> Owner's Name Phone3 ,L7,?/ , <br /> Address City <br /> Contractor's Name �. License Phone3 � <br /> i <br /> TYPE OF WORK (Check) : .NEW WELL / / DEEPEN/_/ RECONDITION /_7 DESTRUCTION / <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <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 /> _..-.Indus_tr.ial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic <br /> 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 /> i <br /> PUMP REPLACEMENT RT—State Work Done <br /> PUMP .REPAIR: / / State. Work Done <br /> DESTRUCTION 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 before putting the -well in use. The above <br /> information is true to the be of- my kn ledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUT AN A F NSPECTIO . <br /> SIGNED TITLE <br /> W• Pt T PLAN ON REVERSE SIDE 7� 7=11: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I l <br /> APPLICATION ACCEPTED BY DATE l r 7 <br /> ADDITIONAL COMMENTS: 0 <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE e-7 7 <br /> E H 1426 Rev. 1-74 <br /> 3/76 2M <br />