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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE USE: / 1601 E. Hazelton Ave. , Stockton, Calif. ��`'-a;f <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Ap-1•icat.i,on is hereby made to the San Joaquin Local Health District for a permit to construct <br /> arii�'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 /> JOB ADDRESS/LOCATION p ,CS /f.� <br /> ENSUS TRACT <br /> Owner's Name -7- Phone <br /> Address <br /> /�1 1 <br /> Contractor's Name 0(�✓/✓e/L License # P one <br /> TYPE OF WORKCheck) ; <br /> � NEW WELL / / DEEPEN/_/ RECONDITION / ON <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 �1 <br /> INTENDED D USg TYPE OF WELL CONSTRUCTION SPECIFICATIONS (� <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilledvi <br /> Dia. of Well Casing v <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation ' <br /> Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: Q <br /> PUMP INSTALLATION: Contractor $f I- F <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP . ]:R: <br /> / / State Work Done <br /> DES• RUCTION OF WELL: W 11 Diameter �� / ► , <br /> ��—�-- Approximate Depth <br /> escribe Material and Procedure <br /> I here 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 0 GROUT G AND A FIN N. <br /> SIGNED <br /> TITLE a _ <br /> DRAW- P ! T PLAN ON RE ERSE SIDE} <br /> PHASE I <br /> , C 7 FOR DEPARTMENT USE ONLY <br /> 1 <br /> APPLICATIO CCEPTED BY DATE _ 2 7-- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTI N PHASE /FIN INSPECTI N <br /> INSPECTION BY AAT INSPECTION BY TE Z <br /> E H 1426 Rev. 1-74 i3/76 <br /> -- <br />