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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. glrJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> i <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health Distract 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 2- CENSUS TRACT . <br /> Owner's Name Phone <br /> w ! <br /> Address' ,d, City, t <br /> i <br /> Contractor's Name License # hone <br /> J <br /> TYPE OF WORK (Check) : NEW WELL E .. DEEPEN '/ / RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTALLATION '/ / PUMP REPAIR/ / PUMP REPLACEMENT /-7 l <br /> i Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER'LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINES-- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED �USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial able Tool Dia. of Well Excavation <br /> �mestic/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 _2 7-0 / <br /> -Disposal Other - Other Information <br /> Geophysical S' face Seal Installed By: <br /> h <br /> PUMP INSTALLATION: Contractor ' <br /> Type of Pump H.P. r <br /> PUMP REPLACEMENT: j_/ 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 bjaAt of my. knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR I A '. IN ECTMN. <br /> ,SIGNED TITLE <br /> DRAW L T PLAN ;ON REVER7C4�. <br /> SE SI <br /> R DEPARTMENT USE ONLY <br /> PHASE I ? <br /> APPLICATION ACCEPTED BY DATE f/ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTI N <br /> INSPECTION BY DATE '77/ INSPECTION BY DATE <br /> -- - ` <br /> E H 1426 Rev. 1-74 <br /> 3/76 2M <br />