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SAN JOAQUIN� LOCRL HEALTH DISTRICT <br /> F0T'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7s 1�3, <br /> THIS PERMIT EXPIRES I YEAR FROM_DATE ISSUED. Date Issued o�q_ad <br /> (Complete In Triplicate) <br /> Application id 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 Districe. <br /> JOB ADDRESS/LOCATION - CENSUS TRACT <br /> Owner's Name Phone r3 �- S <br /> Address , 4City ' <br /> Contractor's Name / License # Phone - f►3! <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN /_ RECONDITION /— DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR/� PUMP REPLACEMENT /7 <br /> Other <br /> L/ <br /> DISTANCE TO NEAREST: SEPTIC TANK �-- SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER p� <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL 4� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS p <br /> Industrial Cable Tool Dia.. of Well, Excavation � <br /> _� Domestic/priva.te L---'Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 10,19 411 <br /> Irrigation Gravel Pack Depth of Grout Seal " <br /> Cathodic Protection Z-- Rotary Typ, f Grout <br /> _, Disposal Other t Information <br /> Geophysical Surface Seal Installed By: eo,­ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMF .REPAIR: / J State Work Done <br /> DESTRUCTION_ OF WELL: Well Diameter4 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-best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AN AL INS CTION <br /> SIGNED 2 TITLE <br /> DRAWPMT PLAN ON REVERSE SIDE <br /> 0 DUPARTMENT USE ONLY <br /> PHASE I g <br /> APPLICATION ACCEPTED B DATE7- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 r _ 4/75 2m <br />