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�{ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ?7-/n 9p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued7,Z <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 /> .TOB ADDRESS/LOCATION U-3 7 �� � �1 rC '�/( al CENSUS TRACT <br /> Owner's Name Phone <br /> City S <br /> Address r <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check) : NEW WELL/7 DEEPEN '/ / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION %I 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 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 6 <br /> Domestic/public Driven Gauge of Casing \ „ <br /> Irrigation Gravel Pack Depth of Grout Seal v) <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 /> JJ <br /> PUMP REPLACEMENT: _I State Work Dane _� �ll eT S/ �d z �� <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameters Ap roxi�a De <br /> D cr bJe/_,Raterial and Procedure <br /> r 'Cl d <br /> I hereby agree to comply-wi..th a and-regulations _ the,San.•J•oaq,&in-L c"al 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 SROMaD A FINAL INSPECTION. <br /> SIGNED TITLE <br /> D W P I PLAN ON <br /> 85E SIDE i... }; <br /> FOR DEPARTMENT USE ONLY <br /> PHASE X <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL CONNtNTS: <br /> PHASE II GROUT IN M CTION PHASE jTtILrNAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY - DATE 4 7. <br /> I 3/76 <br /> E H 1426 Rev. 1-74 <br />