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4�b � SAN JOA4UIN-tOCAL HEALTH DISTRICT <br /> FOR,.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209)466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 <br /> 4 <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 CENSUS TRACT <br /> Owner.'s Name4 <br /> Phone <br /> , <br /> Address - - _ •..._ City <br /> Contractor'a Name ZzzgL License # Phone.' = . <br /> t <br /> TYPE OF WORK (Check): NEW WELL /47'-DEEPEN /? RECONDITION /-' DESTRUCTION f7 <br /> AL <br /> PUMP INSTLATION PUMP REPAIR /7 PUMP REPLACEMENT /? <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> s PROPERTY LINE -- PRIVATE DOMESTIC WELL ' PUBLIC DOMESTIC WELL [� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS F V <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of. Well Casing /Q <br /> F Domestic/public Driven Gauge of Casing /�? , Y4 <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 /> k Type of Pump <br /> ' PUMP REPLACEMENT: / / State Work Done _ <br /> PUMP 'REPAIR: J7 State Work Done <br /> E&TRUCTION OF WELL: Well )Diatmeter 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•'bes,of my-knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED �—' TITLE / <br /> a DRAW PLOT PLAN ON REVERSE SIDE <br /> �> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION-,ACCEPTED BY DATE <br /> ADDITIONAL COMME S•,. <br /> P INSPECTION PEAS III N INSPECTION <br /> INSPECTION BY DATE _ t` INSPECTION BY urc DATE <br /> li E H 1426 Rev. Z-74 1-74 214 �I <br />