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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 7- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is her yi 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 and1the Rules and Regulations of the Sart Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name ZZ"` . License #:Z&g22epone y <br /> r <br /> TYPE OF WORK (Check): NEW WELL/_7 DEEPEN '/_7 RECONDITION fT DESTRUCTION f7 <br /> PUMP INSTALLATION PUMP REPAIR/_7 PUMP REPLACEMENT f 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 t. Cable Tool Ilia. of Well Excavation �1 <br /> Domestic/private r Drilled Dia. of Well Casing <br /> Domestic/public i Driven Gauge of Casing ' <br /> Irrigation J Gravel Pack Depth of Grout Seal { <br /> Cathodic Protection A Rotary* Type of Grout <br /> Disposals Other Other Information <br /> -Geophysical <br /> - - .. r� . _ - Surface_ Seal Installed 'By i <br /> Y� <br /> PUMP INSTALLATION: Contractor 9 <br /> Type .of Pump H.P. <br /> PUMP REPLACEMENT: . <br /> / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> ,t <br /> DESTRUCTION OF WELL Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> .9 <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 FINA& 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 IIINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYATE <br /> E H 1426 Rev. 1-74 h/75 2M <br />