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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave, , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PURR' PERMIT Permit No. 7,7- <br /> THIS <br /> 7THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,` 2'7 <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. 1`862 and the Rules and Regulations of the San Joaquin Local Health District.. <br /> JOB ADDRESS/LOCATIONt`?- �p ENSUS TRACT <br /> Owner's Name Phone <br /> Address 162-1 <S"�- City <br /> Contractor's Name License # Phone ' <br /> i <br /> TYPE OF WORK {Check) : NEW�WFLL / DEEPEN /? RECONDITION / DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT / <br /> Other J / <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 WEL <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 z� <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: . <br /> PUMP INSTALLATION: Contractor AV <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: .' / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DES 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 FIFTERK 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 abddve <br /> information is true to the best of- my-knowledge and belief. I WILL CALL FOR A GROUT i0PECTIi,- <br /> PRIOR TO GRO TING D► .FINAL INSPECT ION. <br /> SIGNED TITLE <br /> D WPLAN 'ON SE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I f� <br /> APPLICATION ACCEPTED BYDATE 5' <br /> ADDITIONAL COM TS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE /7-7)' <br /> r- E H 1426 <br /> Rev. 174 <br />