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SAN JOAQUIN LOdAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 '' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP' PE MIT Permit No.'_ 7�ra�/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued . <br /> (Complete In Triplicate) <br /> ApplicationAs hereby made t6 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 L <br /> County Ordinance No. 1862andthe R nd Reg ions- of the San Joaquin Local Health District <br /> JOB ADDRESS/LOCATW <br /> CENSUS TRACT <br /> Owner's Name Phone4lk -17 <br /> Address City* <br /> Contractor's Name License 3�5 Phone�496/9 <br /> TYPE OF WORK (Check) : NEW WELL /-7 DEEPEN/=7 RECONDITION /_7 DESTRUCTION /7 r <br /> PUMP INSTALLATION/ / PUMP REPAIR PUMP REPLACEMENT /7 <br /> Other I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - PIT PRIVY <br /> SEWAGE .DISPOSAL--FIELD—_- -._- CESSP00L/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL k <br /> INTENDED USE TYPE OF WELL', CONSTRUCTION -SPECIFICATIONS (� <br /> Industrial i Cable Tool Dia. of Well-.Excavation <br /> Domestic/private I . Drilled• Dia. of Well Casing.," <br /> Domestic/public _ 1 - Driven Gauge of Casing <br /> 1�- Irrigation 1, Gravel Pack Depth of Grout. Seal 1 <br /> Cathodic.Protee tion: * : +.A. Rotary Type of. Grout <br /> 'Disposal : t Other Other Information <br /> Geophysical � Surface Seal Installed By . <br /> PUMP INSTALLATION: Contractor k; <br /> Type of- Pump H.P. <br /> PUMP REPLACEMENT / / State Work Done <br />'PUMP .REPAIR: /�State Work -Do <br /> AES•TRUCTION OF WELL: Well Diameter ;y-4 �;e ` 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 SAYS, <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 guy knowledge and belief. I WILL CALL FOR A GROUT 14SPECTIOI+T; 1 <br /> PRIOR TO GROU ING AND A FINAL ,INSPECTION. :•.,k <br /> SIGNED TITLE <br /> (DRAW PLOT' PLAN''ONtSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I I <br /> APPLICATION ACCEPTED BY '' DATE <br /> ADDITIONAL COMMENTS: <br /> .,PHASE II^GRO _ MSPECTION PHASE_ III�FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY _ DATE- <br /> E H 1426 Rev. 1-74 3/76 2A4 <br />