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SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 7V <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued�a�� <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 _ /€.� 0,+�`/� D CENSUS TRACT ' <br /> Owner's Name C.. P„ 4ePhone1 jI- <br /> Address City <br /> Contractor's Name A ('had 11 License A & Phone, . <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/-7 DEEPEN /-7 RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / , PUMP REPAIR / / PUMP REPLACEMENT <br /> Other l <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 YELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing 0. ' <br /> Domestic/public Driven Gauge o"Casing <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: <br /> Contractor �" �.�• �� <br /> Type of Pump H.P. <br /> I <br /> PUMP REPLACEMENT: / State Work Done ,o <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION 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 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 GROUTING 4ElbA FINAL INSPE O <br /> SIGNED -o TITLE <br /> 1"OMW. PwT PLAN ON REVtRSE SIM 7 <br /> FO PARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL CONMTS: <br /> PHASE II GROUT INSPECTION PHASE III/]FINAL INSPECTION . <br /> INSPECTION BY DATE INSPECTION BY DATE - D <br /> E H 1426 Rev. 1-74 <br /> V76 2K. <br />