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I <br /> C6 Id SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFs'- T E USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> �10 Telephone: (209) 466-6781 p <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 75 0 3 <br /> THIS PERMIT EXPIRES ITYEAR 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. aid the Rules <br /> eRules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATNIOS r� � _ CENSUS TRACT <br /> bvmer r s Name <br /> Phone S <br /> Address _ f s� .r".�c ` City <br /> ' License # / & 7�S Phone a� �' 7621- <br /> Contractor s Name <br /> TYPE OF WORK (Check) : NEW WELL /-7 DEEPEN -/? RECONDITION /? DESTRUCTION - <br /> PUMP INSTALLATION / I PUMP REPAIR /� PUMP REPLACEMENT <br /> Other <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 N <br /> Domestic/public k Driven. Gauge of Casing 1 <br /> IrrigationG ravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other s Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: ContractorF <br /> Type of Pump w / H.P. <br /> PUMP REPLACEMENT: / State Work Done <br /> PUMP `-REPAIR: /-7° State Work Done <br /> i <br /> Approximate Depth <br /> ES;TRUCTION OF WELL: Well Diameter pp <br /> r <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 4 <br /> WELL TIRILLER5�REPORT of the well and notify t em before putting.the. well in-use.. The above <br /> 11—information`1i - true to the-best-of my knowle a and`sbelief.. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO �GROUT NG AND A FINAL INSPECTI, . <br /> SIGNED TLE <br /> (D W PLOT LAN ON RSE SID ~ <br /> R DEPARTMENT USE ONLY <br /> PHASE I f <br /> APPLICATION ACCEPTED>4'.BY DATE --c - <br /> �. ADDITIONAL COMMENTS: PHASE III FINAL INSPECTION <br /> PHASE II GROUT .INSPECTION _ <br /> INSPECTION BY ,I DATE INSPECTION BYy 9S _ DACE . <br /> E H 1426 Rev. 1-74 s' 1-74'2M <br />