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SAN <br /> JOAQUIN LOCAL HEALTH DISTRICT <br /> 70F.7OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /,E-4, 76 <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 th Ruleq and Regulations the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name ifi ..� Phone <br /> Address __-- PhC 2-CP City <br /> Contractor's Name t � License # &2(�17.Phone <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN ,/7 RECONDITION f-f DESTRUCTION /—f <br /> PUMP INSTALLATION LT�'PUMP REPAIR/-7—PUMP REPLACEMENT J <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 DOWSTIC 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 /> 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: /-7 State Work Done <br /> \' <br /> PM .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 CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUT AND A FINAL INSPECTION. <br /> SIGNED . TITLE <br /> DRAW PLOT PLAN ON REVERSE SID� <br /> PHASE I <br /> FOR DEPARTMUT USE ONLY <br /> APPLICATION ACCEPTED BY 9-- DATE` 2 <br /> ADDITIONAL COMMENTS: <br /> COMMENTS <br /> PHASE II GROUT INSPECTION PHM 11IPFINAL INSPECTION <br /> INSPECTION BYDATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 2M <br />