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SAN JOAQUIN LOCAI `kALTH DISTRICT <br /> FOFi,,OFFICE USE: . .. <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> k APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �6-5771 <br /> i <br /> THIS PERMIT EXPIRES l YEAR FROM DATE 'ISSUED Date Issued <br /> ]. (Complete In Triplicate) r <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 the San -Joaquin Local Health District,. <br /> JOB ADDRESS/LOCATION 2 7 CENSUS TRACT <br /> Owner's Name ' s <br /> l S <br /> Phone <br /> Address. ��:Z� City . <br /> Contractor's Name License # 4 0�0 Phone <br /> TYPE OF WORK (Check); NEW WELL DEEPEN '/� RECONDITION %f DESTRUCTION f7 <br /> E PUMP INST LATION '/ / PUMP REPAIR'/� PUMP REPLACEMENT /7� <br /> j Others' %/ <br /> DISTANCE TO NEAREST: SEPTICiTANK SEWER LINES PIT PRIVY <br /> SEWAGEIDISPO AL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL': - PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRRUCTION SPECIFICATIONS <br /> Industrial 4 Cable Tool Dia. of Well Excavation <br /> Domestic/private I Drilled Dia. of Well Casing <br /> Domestic/public Driven <br /> Irri8 Gauge of Casing <br /> atio <br /> n # Gravel Pack Depth of Grout,.Seal <br /> Cathodic Pr_otect_ion I Rotary Type.of Grout <br /> Disposal ' <br /> Other . Other Information -- <br /> Geophysical <br /> Surface Seal Installed 'B : <br /> PUMP INSTALLATION: Contractor <br /> Type .of Pump H.P. <br /> PUMP REPLACEMENT: State Work Dane <br /> PUMP REPAIR: /7 ,State,Work Done " . <br /> OES1TRUCTION 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..well. in.use.. The above <br /> information is true to the•best -of- my-knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br />' PRIOR TOG OUTING AND A FIN AL"INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY x DATE <br /> __ - - .d..... _- <br /> ADDITIOPIALCOMMENTS <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY Q,a _ DATE ./ <br /> E H 1426 Rev. 1-74 <br />