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i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT t <br /> FOh OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 (� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> F <br /> THIS ;PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1r -7r <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. 18/62 and the Rules and Regulations of the San Joaquin Local Health District. I <br /> JOB ADDRESS/LOCATION ! CENSUS TRACT r <br /> rf <br /> awner s Name Phone 8�) <br /> AddressCit <br /> c ^LY) <br /> y <br />)ontractor's Name "g License Phone <br /> Q <br /> HYPE OF WORK (Check) : NEW WELL; / / DEEPEN / / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION LP/7 PUMP REPAIR/ / PUMP REPLACEMENT /- <br /> Other <br />)ISTANCE 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 <br /> Industrial Cable Tool Dia. of Well Excavation f <br /> Domestic/private Drilled Dia. of Well Casing I <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout , <br /> i <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: <br />?UMP INSTALLATION: Contractor Com° <br /> Type of Pump H.P. ' <br />?UMP REPLACEMENT / / State Work Done <br /> i <br />?UMP '.REPAIR: / / State Work Done <br />►E&TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> C hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> ind the State of California pertaining to or regulating we11 '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 /> BELL DRILLERS REPORT of the well and notify them before putting the wellin use. The above <br /> Lnformation is true to the best ofmy knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />'RIOR TO 92UTING A INA I PE CT ION. <br /> iIGNED TITLE -Q <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br />?RASE I <br /> APPLICATION ACCEPTED BY /\ DATEr� <br /> 1DDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION f PHASE I <br /> ,,�I/VIN4 INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE�2-� <br /> E H 1426 Rev. 1--74 �f.77 <br />