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Co /"1&WC SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOB OFFI USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S-,3$ r� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued5� <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 f the San Joaquin Local Health District. . <br /> JOB ADDRESS/LOCATION / 10 CENSUS TRACT <br /> Owner's Name .—T/l <br /> Phone <br /> Address Cityriyw <br /> Contractor's Name License # ��Phoney � G <br /> TYPE OF WORK (Check): NEW WELL 17 DEEPEN /7 RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR '/-7—pump REPLACEMENT R <br /> Other /% <br /> i <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 � I <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 <br /> Type of Pump Al. H.P. <br /> PUMP REPLACEMENT: )ff State Work Done <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 myowle a and elief. I' WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU ING AND A FINAL INSPECTI0 <br /> SIGNED <br /> (D W15XOT REV SE SIDE <br /> PHASE I <br /> REP <br /> DARTMENT USE ONLY <br /> ,F} <br /> APPLICATION ACCEPTED BY X9 DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT IN5nCTION PHASE III/FINAL INSPECTION f <br /> INSPECTION BY w DATE INSPECTION BY iffgh DATE 9-2, '�T <br /> ef <br /> E H 1426. Rev. 1-74 r" h/75 2M <br />