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E SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> PW OFFICE USE: 1601 E. Hazelton Ave. , .Stockton, Calif. <br /> �. <br /> Telephone: (209)' 466-6781 �� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE 'ISSUED Date Issued / <br /> E I (Complete In Triplicate) I.C-7� 310 - Z O <br /> Application is hereby made to the San Joaquin Local health District for a permit to construct <br /> j and/or install the work herein described. This application is made in compliance with San Joaqu: <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin .Local Health District:' <br /> JOB ADDRESS/LOCATION ALE CENSUS TRACT <br /> Owner"s Name r—pu-, Phone <br /> Address City <br /> Contractor's Name License #/ 1 Phone Z4 24 <br /> TYPE OF WORK (Check): NEW WELL/_ DEEPEN -/7 RECONDITION %7 DESTRUCTION f7 <br /> PUMP INSTALLATION ,/. / PUMP REPAIR- � PUMP REPLACEMENT /? <br /> Other / / <br /> rDISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY o . <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER \N_ <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL ih <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS � <br /> Industrial i Cable Tool Dia. of 'Well Excavation <br /> ._T Domestic/private i Dulled Dia. of Well Casing <br /> Domestic/public , i EDtiven Gauge of Casing <br /> Irrigation F Gravel Pack Depth of Grout Seal <br /> Cathodic Protection '. - Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical .�: j Surface Seal 'Insta1ldd 'By: <br /> PUMP INSTALLATION: Contractor fL.Gf <br /> Type of Pump - H.P. �` <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: State Work Donee -' <br /> [ PE&TRUCTION ,OF WELL: Well Diameter Approximate Depth <br /> r <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"cons truction Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin 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 GOUTING AND A FINAL I-NSXMON <br /> :SIGNED / ITLE r6 . <br /> PLOT PLAN ON RVEME SIDE <br /> FOR DEPARTMENT USE ONLY <br /> +PHASE I <br /> .'APPLICATION ACCEPTED BY .DATE <br /> ADDITIONAL COMMENTS: r' <br /> { PHASE II GA T PECTION `PHASE III/FINAL INSPECTION <br /> J -INSPECTION BY DATE INSPECTION BY / DATE ,P,- 49 <br /> E. <br /> E R 1426 Rev. 1-74 __ _ /75 2M <br />