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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOH OFFICE USE: --- 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.,7 _ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssuedS_ <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 Regulation a the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIO CENSUS TRACT <br /> Owner's Name phone <br /> Address U- OS14. <br /> S City <br /> f <br /> Contractor's Name g� License #,�2 Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ f DEEPEN/_/ RECONDITION AL / _ <br /> _/ DESTRUCTION / <br /> PUMP INSTLATION f / 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 /> Industrial Cable Tool Dia. of Well Excavation CIN' <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 Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed' By: <br /> J <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 47- H.P. <br /> PUMP REPLACEMENT: / / State Work Donei�-6' <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 best of my knowledge and belief. ' I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO TING AND AL INSPECT40N. <br /> SIGNED TITLE i <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 9 /-77ADDITIONAL COMMENTS: - ------- _ <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE-43 -77 : <br /> E H 1426 Rev. 1-74 1/77 2M <br />