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r� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 16011 E. Hazelton Ave. , Stockton, Calif. ` <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �7.73a <br /> THIS PERMIT EXPIRES 1 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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ! CENSUS TRACT <br /> Owner's Name p 'yam Phone <br /> Address <br /> City <br /> Contractor's Name D License #A �hone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN RECONDITION RECONDITION /_/ DESTRUCTION y" <br /> PUMP INSTALLATION / -0 REPAIR / / PUMP REPLACEMENT" 1-7E <br /> Other ' <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PTT 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 <br /> /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 By: <br /> PUMP INSTALLATION: f ' <br /> Contractor <br /> Type of Pump H.P. r <br /> PUMP REPLACEMENT: / / State Work Done a <br /> PUMP �REPAIR: /% State Work Done <br /> DESTRUCTION OF WELL: Well Diameter kp rax' at Depth 1i <br /> Describe Material. and Procedure �� d <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 true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION i <br />?RIOR TO G OU INGPE ION. <br /> SIGNED TITLE <br /> (D W PLOT PLAN ON REVERSE SIDE) ! <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �~ PATE �r <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I/ INAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br />. „E H 1426 Rev. 1-74 -1/Z.7 2M <br />