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I UN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0,-_ OFFICE USE: 160. Hazelton Ave. , Stockton, Cal <br /> Telephone : (209) 466-6781 ' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7 7­11 7 <br /> THIS PERMIT EXPIRES 1-YEAR FROM DATE IS e Issued <br /> Complete In <br /> Application is hereby made t, the San (Joaquin Local rHealthtDistrict for <br /> and/or install the work herein, described. This application is made in compliancetwithnSan uJoaqui3 <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owners Name <br /> Phone <br /> Address rj <br /> City <br /> Contractor's Name <br /> License 163dL Phone : <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN I I RECONDITION / � <br /> _/ DESTRUCTION _ _ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT / <br /> Other 1/ / --- <br /> . f .: <br /> 7— <br /> DIS ANCE TO NEAREST: SEPTIC TANK 0 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LITE`- PRIVATE DOMESTIC,WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation` �� \ <br /> ^X Domestic/private 3 Drilled Dia, of Well Casing <br /> Domestic/public i Driven Gauge of Casing <br /> Irrigation 1 Gravel Pack Depth of Grout Seal <br /> Cathodic Protection X71 Rotary Type of Grout <br /> Disposal 1 Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: * ~ <br /> Contractor r <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: I <br /> S!tate Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> 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 puttingthewell in use... The above <br /> information is CX:ue to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION I <br /> PRIOR TO GOUTI$ AN A FINAL INSPECTION. <br /> SIGNED TITLE <br /> I <br /> 1 (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br />,ADDITIONAL COMMENTS: 1 DATE 'a <br /> 1'+ PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> `NSPECTION BY DATE INSPECTION BY <br /> 77 2M <br /> E H 1426 Rev- 1-74 � : f <br />