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A-4' 13 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR' OFFICE USE: '16.01 E. Hazelton Ave. , . Stockton, Calif. <br /> Telephone .p one : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No 7 //�� <br /> THIS PERMIT. EXPIRES l 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 d Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATI ENSUS TRACT <br /> �V <br /> Owner's Name <br /> Phone JrJ <br /> Address <br /> city s <br /> Contractor' e <br /> License #o0:N6rddPhone <br /> a <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN%/ RECONDITION <br /> L/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / PUMP REPAIR / PUMP REPLACEMENT <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 PUBLICDOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation _1 <br /> Domestic/private Drilled Dia. of Well Casing \� <br /> Domestic/public Driven Gauge of Casing <br /> Irrigatibiia "" x'" Graves Pack Depth of Grout Seal ` <br /> Cathodi-c-protection - Rotary _ - Type of--Grout <br /> Disposal Other Other Information. + � <br /> Geophysical Surface Seal Installed B : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H. . <br /> PUMP REPLACEMENT: <br /> /" / State Work Done Y --� <br /> PUMP .REPAIR: <br /> / / State Work Done - <br /> DES-TRUCTION 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 />'RINE TO G OUTING ) FINAL INSPECTION. <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I , <br /> APPLICATION ACCEPTED BY Z, <br /> DATE '3� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P S FIN4L NSPECTIO <br /> Lq <br /> INSPECTION BY ]]ATE 00V� INSPECTION B DATE 3 <br /> E H 1426 Rev. . 1-74 0/77 9M <br />