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A <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE,OfiiCE USE: �1. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No,7--7 f <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date,Issued -! <br /> (Complete In Triplicate) <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. 186 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATI, Am('11l'ifc <br /> CENSUS TRACT <br /> ��9�.369-a9,�s • <br /> Owner's Name Phone� <br /> Address f r+ rczCity <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN/7 RECONDITION /7 DESTRUCTION f <br /> PUMP INSTALLATION / / PUMP REPAIR/-7 P REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER I <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 _ 3e , Rotary Type of Grout <br /> Disposal Other Other Information <br /> ;!_Geophysical ..-�-... - <br /> Surface Seal Installed By: I <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump A.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP 'REPAIR: / / State Work Done <br /> DESTRUCTION 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 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 GROUTINGD A FIN NSPECTION. <br /> SIGNED TITLE J <br /> (DRAW T PLAN ON REVERSE SIDE ~� <br /> PHASE I <br /> OR DEPARTMENT-USE ONLY <br /> APPLICATION ACCEPTED H DATE <br /> ADDITIONAL COMMENTS: <br /> + PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1.-74 � Gam" � �.t/75 2M <br />