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y Poll-SAN JOAQUIN LOCAL HZA&TH DISTRICT <br /> F0E70FF_ E USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued &-,3_7 <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 �-7c / !�j /e:: CENSUS TRACT <br /> Owner's Name �� � �� e C/X Phone <br /> Address City <br /> Contractor's Name 5e l License # Phone <br /> TYPE OF WORK (Check): NEW WELL/_ DEEPEN /-7 RECONDITION /_j DESTRUCTION <br /> PUMP INSTALLATION REPAIR/� PUNP REPLACEMENT /-7 <br /> Other / 7 <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 ff <br /> Industrial Cable Tool Dia. of Well Excavation Vi <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing v <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 A.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP ,REPAIR: / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 169 Approximatepth <br /> 641261-a- <br /> Describ Material a d Procedure <br /> r w! , <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-best-of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G ING AND FINAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I R DEPARTMENT USE ONLY <br /> APPLICATION CATION ACCEPTED BY10,4,4.1fDATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION 41 P AQ1W I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE kQL .I&76 <br /> E H 1426 Rev. 1-74 h/75 2m- <br />