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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FCR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) /2 p _ ��77 <br /> Application is hereby made to the San Joaquin Local Health District for a permi tto 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 of the San Joaquin Local Health District. <br /> f� Pa:ZZ <br /> JOB ADDRESS/LOCATION -lif <br /> CENSUS TRACT <br /> Owner's Name ,/' �' f---) jwure. Phone <br /> Address <br /> Contractor's Name License ` - �q ��` <br /> hone <br /> TYPE OF WORK (Check): NEW WELL /? DEEPEN /% -RECONDITION /-7 DESTRUCTION %f 1: <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT /- O <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY N <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PITS— . L 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 7- <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 B : <br /> PUMP INSTALLATION: Cantraator <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: j/1- State Work Done <br /> PUMP .REPAIR: - <br /> / /T State Work Don € ., <br /> 1 <br /> ES•TRUCTION OF WELL: Well Diameter <br /> Approximate Depth l <br /> Describe Material and Procedure ----�--y y' <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 . <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. a <br /> SIGNED ' <br /> TITLE aaj� <br /> (DRAW PLOT PLAN ON REVERSE SIDE '````A J-Al <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE 3 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P IIYOAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> r <br /> E H 1426 Rev. 1-74 <br /> 1 1-74 7M <br />