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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,7,1/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -! <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. 186 and _the Rul a Reg ations of the San Joaquin Local. Health District. � <br /> p��y <br /> JOB ADDRESS/LO TION CENSUS TRACT <br /> Owner's NamPhon6 4z17 U <br /> Address City /_ <br /> Contractor's Name `, 's �1� <br /> Licens 'hon <br /> TYPE OF WORK (Check) : NEW WELL /? DEEPEN -/ / RECONDITION / / YDESTRUCTION % � J y <br /> PUMP INSTALLATION/ / PUMP REPAIR /Z__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 By: <br /> PUMP INSTALLATION: Contractor (R <br /> Type of Pump. H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP .REPAIR: - -.— - State Work Do _ <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 GROUTING AND A FI AL INSPECTION. <br /> SIGNED7?1TITLE <br /> (Dk&TW PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE T <br /> APPLICATION ACCEPTED BY DATE �Q <br /> ADDITIONAL COMMTS: <br /> PHASE TI GROUT, IT <br /> qSPECTION. PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE _ INSPECTION BY ^^ DATE <br /> E H 1426 Rev. 1-74 Cto 3/76 : j <br />