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SAN. JOAQUIN LOCAL-HEALTH DISTRICT <br /> FOR'IOFFICE USE: .1601 E. Hazelton Ave. , Stockton, Calif. <br /> 'Telephone: �,`i(20_9) 466-6781 <br /> APPLICATION'TOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. • 7- 7 <br /> 7: a �7 a 85►� <br /> THIS PERMIT;.RXPIRE-S^ Ii;YEAR FROMi-DATE ISSUED,- Date IssuedF -7' <br /> (Complete In Triplicate) <br /> Application is hereby made to the.:-San Joaquin•_Local,Y.IIealth:District for a permit to construct <br /> and/or .install. the work herein:.descr ibed., ..,This application is made in compliance with San Joaquin <br /> County Ordinance No. 186 and Rulee and .Regulation�f. San�oaqui Local ealth District. <br /> A <br /> JOB ADDRESS/LOCATION . S � CENSUS TRACT <br /> Owner's Name Phone <br /> Address - � .- . ...: - City -- <br /> Contractor's Name License #X17 Phone 3"-33 3 <br /> TYPE OF WORK (Check): NEW WELL /�EEPEN:'/-7 RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTALLATION /TT PUMP REPAIR /7 , PUMP REPLACEMENT <br /> Other.. _ .: e ...-.. <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 (A <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 /> �riigation Gravel Pack Depth of Grout Seal _ IN <br /> Cathodic Protection Rotary ,Type of-Grout^ <br /> Disposal Other Other Anform tion <br /> Geophysical Surface Seal"Installed By: _ <br /> PUMP INSTALLATION: Contractor " <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done*'` <br /> PUMP :REPAIR: �� / --State Work Done <br /> ,pES-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 thew 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 faROUTING AN FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY :' DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PRASE III FINAL INSPECT ON <br /> INSPECTION BY DATE INSPECTION BY DATE z <br /> E H 1426 Rev. 1-74 1-74 2M <br />