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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT ' permit Na. 7f° 1 <br /> y <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> 02( W'^:J"S -. (Complete In Triplicate) 0 1-36 t <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. 1.862 and the Rules and Regulations of the San Joaqu Local HealthWtrict. <br /> JOB ADDRESS/LOCATION7G� <br /> CENSUS TRACT <br /> Owner's Nasse <br /> .. d Phone <br /> Address City <br /> Contractor's Name F� ` - License LW&IR Phone <br /> TYPE OF WORK (Check): NEW WELL/-7 DEEP J-7 RECONDITION /7 DESTRUCTION f7 ` <br /> PUMP INSTALLATION /� PUMP REPAIR /—/ PUMP REPLACEMENT <br /> Other / J <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 <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 .1 <br /> Disposal . Other Other Information <br /> Geophysical Surface Seal Installed BY: +F+ <br /> 11 <br /> PUMP INSTALLATION: Contractor r ;I <br /> Type of Pump IK H.F. j }� <br /> PUMP REPLACEMENT: / / State Work Done rJ <br /> PUMP, REPAIR: /? State Work Done _ <br /> ES:TRUCTION 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 sem► work on a new well, I will furnish the San Joaquin Local Health District <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 CAJPFOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AN FINAL INSPECTION. <br /> SIGNED TITLE <br /> fool (DRAW PLOT PLAN ON REVERSE SIDE) ` <br /> FOR DEPARTMENT USE ONLY f <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE -II-GROUT INSPECTION PHASE IIJ INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYE/ TE <br /> 1 E H 1426 Rev. 1-74 -1_7/. „m <br />