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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. '7-7-4j/0, <br /> l THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) r <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 an Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner`s Name I Phone <br /> Address ,� 3 City <br /> i <br /> Contractor's Name J License # .ePhone � �l�, <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN I / RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLAT / / PUMP REPAIR//_/ PUMP REPL EMENT <br /> Other i/ — <br /> DISTANCE TO NEAREST SEPTICjTANK 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 N-1 i <br /> Industrial 1 Cable .Tool . Dia. of Well Excavation <br /> Domestic/private #" Drilled' . ° Dia. of Well Casing <br /> Domestic/public :I DrivenGauge of Casing <br /> Irrigation i Gravel Pack Depth of Grout Seal <br /> Cathodic Protection I Rotary Type of Grout <br /> Disposal Other - Other Information <br /> Geophysical ' ='` Surface Seal Installed B : <br /> -PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. p` <br /> PUMP REPLACEMENT <br /> / / State Work Done <br /> PUMP .REPAIR: /% State Work Done <br /> STRUCTION OF WELL: Well Diameter $ Approximate ept.h <br /> DescribeMater al and Procedure L- T -p y �� <br /> I hereby agree tocomply withiall laws arfdregulations of the San Joaq n o 1h s is <br /> and the State of California pertaining- to or regulating well construction. Within FIFTEE <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 we11 and notify them before putting; the well in use. The above <br /> information is true t the best of. my-knowledge and belief. I WILL C FOR A GROUT INSPECTION <br /> PRIOR TO G TING FINAL INSPECTION. C <br /> SIGNED <br /> TITLE - - <br /> j DRAW- i'L T PLAN 'ON REVERSE SIDE) <br /> 4 <br /> i I FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE Z / <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS I INALSPECTION <br /> INSPECTION BY DATE INSPECTION BY ATE <br /> E H 1426 Rev. 1-74 376 <br />