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:. • SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE.-OFFICE USE: 1601 E. Hazelton Ave. , Stockton,, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �fb/ <br /> a <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued 12—Z- 74_� <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 a the Rules and Regulations of the San -Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION, w 2 <br /> CENSUS TRACT <br /> Owner's Name `" Phone ' <br /> Address City <br />.Contractor's Name License #&yyd Phone <br /> TYPE',=OF WORK (Check) : NEW WELL 17 DEEPEN '/7 RECONDITION L7 DESTRUCTION /7 <br /> i' PUMP INSTALLATION "/7f PUMP REPAIR./ ./ PUMP REPLACEMENT 17 <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 SPECIFICATIONS <br /> . .*Industrial <br /> Cable, Cable Tool Dia. of Well Excavation � � <br /> i'<<Domestic/private Drilled Dia. of Well Casing S <br /> Domestic/public Driven Gauge of Casing fit ' <br /> .; Irrigation Gravel Pack Depth of Grout Seal lv <br /> " Cathodic Protection Rotary Type of Grout <br /> Disposal 'Other Other Information <br /> ,:Geophysical Surface Seal Installed 'B <br /> PUMP 'INSTALLATION: Contractor <br /> F; Type .of Pump H.P. <br /> PUMP REPLACEMENT: - / / State Work Done <br /> PUMP :RBPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth 1 <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 GROUTI AND A FINAL IN ECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVEkSE .SIPEETff__ <br /> FOR DEPART T USE ONLY <br /> PHASE.Iii <br /> APPLICATION' ACCEPTED BYE , <br /> ADDITIONAL COMMENTS: l <br /> PHASE II GROUT INSPECTION PHASE MLFum INSPECTION <br /> INSPECTION BY DATE INSPECTION-BY DATE; <br /> ;t <br />�&_°E H.1426 Rev. 1--74 h/75 2M <br />