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E A„ SAN JOAQUIN LOCAL HEALTH DISTRICT , <br /> FOR 'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. 'NED <br /> Telephone: (209) 466-6781 S <br /> CA14 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.772- 1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued . '3/- 7� <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 /> g gG�JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner s Name Phone <br /> jp <br /> Address City- ' <br /> Contractor's Name <br /> �/ �4 License # Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION f_1 DESTRUCTION /-7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /7 <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 <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-Ay: <br /> PUMP INSTALLATION: Contractor �6 <br /> Type of Pump H.F. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material ano rocedure <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 /> •[�"' <br /> PRIOR TOG UTING AND__A nAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE /FIN INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE P�1*7 <br /> 0!77 2M <br /> E H 1426 Rev. - I-74 <br />