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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F__R?OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 4 7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued7S— <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 Mules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION . 32 1 2 U6 CENSUS TRACT <br /> Owner's Name /� Y Phone IV-G ' 2 <br /> Address / 7-0 Al <br /> City <br /> Contractor's Name ) �/ e 4/. License # Phone <br /> TYPE OF WORK (Check) : NEW WELL /_7 DEEPEN -/-7 RECONDITION 0 DESTRUCTION /7 <br /> PUMP INSTALLATION /7 PUMP REPAIR /7 PUMP REPLACEMENT /7 <br /> Other /_7 <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 <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: j_/ State Work Done <br /> PUMP :REPAIR: /-7 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 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..weli 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 UNG AND A NALiNSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FO TMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED DATES 7 �� <br /> ADDITIONAL COMMENTS: <br /> PRASE II GROUT INSPECTION PHAS III FI AL INSPEC ION <br /> INSPECTION BY DATE INSPECTION BY (-DATE - <br /> 1 <br /> I E H 1426 Rev. 1-74 1-74 2M <br />