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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 PUMP PERMIT Permit No. 7 s <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued/q_/_5)J/ <br /> �1. <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 t San Joaquin Local Health District. J <br /> JOB ADDRESS/LOCATION _ CENSUS TRACT <br /> I <br /> Owner's Name Phone <br /> �`�� -3 <br /> Address <br /> City 127 — <br /> Contractor's Name j� /�C � License ��o�d�--� Phone � - <br /> 6 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION UMP REPAIR / / PUMP REPLACEMENT / <br /> Other 0 ` <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PITPRIVY _ <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 /> k Irrigation Gravel Pack Depth of Grout Seal (� <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of PumpH.P.LC <br /> PUMP REPLACEMENT: / / State_W.ork Done <br /> — i <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material d Procedure <br /> I~hereby agree to ycomply with all laws and regulations of the San Joaquin Local Health District <br /> and the State-of California pertaining-to-or--regulating w&ll-''cdnstruction. Within'FIFTEEN']]AYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> k 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 my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO ROUTING,&_ A FINAL IN.SPECTION. <br /> SIGNED TITLE <br /> f (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE Z 7 <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSP--ktTION PHAS III/FINAL INSPECTION <br /> { INSPECTION BY DATE INSPECTION BY 71 DATE <br /> / <br /> . 6/7!-� 2M <br /> E H 1426 Rev. � 1-74 r�o� <br />