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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE'iOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 T I <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 79- 31.7 r <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued egg{ <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 Ruled egulations of the San Joaquin Local health District. , <br /> F !/'��CENSUS TRACT J► _ <br /> JOB ADDRESS/LOCATION f 4 <br /> 61' L <br /> Owner's Name / c� Phone ., 7- <br /> Address City�03 <br /> �. t. License f ���o <br /> Contractor's Name _ 1 -�Phon i <br /> TYPE OF WORK (Check): NEW WELL -/-7 DEEPENRECONDITION' /? DESTRUCTION f7 <br /> PUMP INSTLATION REPAIR 4 PUMP REPLACEMENT /� <br /> AL <br /> # Other / / <br /> � 1 <br /> DISTANCE TO NEAREST: SEPTICTANK 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 <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,6 REPAIR: -- yS a Work <br /> E&TRUCTION OF 'WELL: Well Diameter Approximate Depth <br /> 4 <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 REP.OR'T,,of the well and notify them before putting the.-well in.use.. The above <br /> information, is'^:tr6e7 to the best of- my knowledge and belief. I WILL CALL FOR,A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A,FINAL INSPECTION. <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> ,4 FOR DEPARTMENT USE ONLY <br /> DATE y <br /> APPLICATIOWS CEPfiED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIO PHASE III FINAL INSPECTION <br /> t' INSPECTION BY-�' DATE INSPECTION BY ATE <br /> 1-74 2M <br /> ,E H 1426 Rev. 1-74 - H <br />