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f SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF,.•OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -i .;n) <br /> 76-.S7 9/o <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued <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 the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 4a/ENSUS TRACT <br /> Owner's Name <br /> Address ^ "b City . <br /> Contractor's Name � ' <br /> LicensQJ j( J-? Phone&�� 2 7 <br /> TYPE OF WORK (Check): NEW WELL /4 DEEPEN -/ RECONDITION / f <br /> f DESTRUCTION / <br /> PUMP INSTALLATION ,�PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other / / <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 vl <br /> Industrial Cable Tool Dia. of Well Excavation �1l <br /> �ffomestic/private Drilled Dia. of Well Casing <br /> —F <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protect_i,on Rotary Type of Grout ?1 <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed Bv: ` j' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump .cgH.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done �. <br /> DESiTRUCTION 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 FOR A GROUT INSPECTION <br /> PRIOR TO GR UT AND ArJUNAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ,S " �l <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY _ DATE S- INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 h/75 2M <br />