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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: ' 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (2091 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMI ermit No. 7 7-.?6 7,P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 5/- 7-7 7 <br /> (Complete In Triplicate) <br /> Application is liiereby 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 oaquin Local Health District. <br /> JOB ADDRESS/LOCATION � <br /> CENSUS TRACT <br /> Owner's Name �y Phone ` <br /> Address [ -'� <br /> city- <br /> Contractor's <br /> ity-Contractor's Name �,C� .License #.--4 Phone <br /> ti <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT &T ' <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY r� <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL (q <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 <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. / <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP -REPAIR: '/ / State Work Done <br /> DESTRUCTION 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 CAL R A GROUT INSPECTION <br /> PRIOR TO G TING FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY v, <br /> PHASE I / <br /> APPLICATION ACCEPTED BY DATE �� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GRO INSPECTION PHASE /FIN INSPECTION <br /> INSPECTION BY ATE INSPECTION BY E - <br /> E H 1426 Rev. 1-74 11I7. -2K <br />