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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 160- 7. Hazelton Ave. , Stockton, Cal <br /> '-'Telephone: (209) 466-6781 ~ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PEPJ41T, Permit No. ,SQ/kJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSU$6' - = Ddte''i'ssued 77 <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 CENSUS TRACT <br /> Owner's Name _ ! Phone <br /> Address City <br /> Contractor's Name r License # - 'Phone <br /> TYPE OF WORK (Check) : NEW WELL Z/ DEEPEN / / RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <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 SPECIF_I_C_A_T_ION_S, v <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal C f <br /> Cathodic ProtectionRotary 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 /> PUMP REPLACEMENT: / / State Work Done <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 GRORTING AND A FINAL INSPECTION. / <br /> SIGNED i TITLE jkwt <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 PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY G DATE <br /> E H 1426 Rev. 1-74 <br /> 3/76 2M <br />