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SAN JOAQUIN LOCAL'HEALTH DISTRICT <br /> *y J <br /> pA OFFICE USE: Ll_ l/v 6; 01 E. Hazelton Ave::,;; .Stockton, Calif. E <br /> Telephone. c (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1-YEAR FROM DATE ISSUED Date Issued7'. <br /> (Complete <br /> In Triplicate) <br /> Application is hereby made toI 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 Ru�l..es.-and-1egulations of the San Joaquin Local Health District.' <br /> • � , r3<<ti p. . - �► �. CENSUS TRACT <br /> JOB ADDRESS AOCATION-' • ti - <br /> Owner's Name Phone <br /> Address t m ; city <br /> ''rr! License # Phones",75-3 yS6 <br /> Contractor's Name . <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/ RECONDITION--T- DESTRUCTION-17 <br /> PUMP -INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT <br /> Othe7rl / / <br /> E DISTANCE TO NEAREST: SEPTICITANK 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 i Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing \ <br /> Domestic/public Driven. - Gauge of Casing 711 <br /> Irrigation : Gravel Pack Depth of Grout Seal <br /> Cathodic Protection t Rotary Type of Grout, <br /> Disposal Other. Other Information <br /> Geophysical 'Surface Seal Installed B <br /> t <br /> PUMP INSTALLATION: Contractor � <br /> Type of Pump kr H.P. /215' -- <br /> PUMP REPLACEMENT: State Work Done <br /> � I I <br /> PUMP :REPAIR: L7 ". State Work Done <br /> QES-,TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hdtd'>y '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 FINAL INSPECTION. <br /> SIGNED - TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT MSE ONLY <br /> PHASE I „ ... DATE <br /> f APPLICATION ACCEPTED BY - <br /> ADDITIONAL COMMENTS: 1i <br /> k PHASE I ROUT INSPECTION PHAS IFI SPECTION <br /> INSPECTION BY , DATE INSPECTION BY DATE <br /> � 1 <br /> 1-7 4 2M <br /> E H 1426 Rev. 1-74 <br /> € <br />