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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. 7,;'- <br /> THIS <br /> JTHIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> i (Complete In Triplicate) <br /> Application is hereby made tolthe San Joaquin Local Health Distri.ct•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 andithe Rules and Regulation's of the San Joaquin Local Health District".' <br /> JOB ADDRESSJLOCATION 1 .2 CENSUS TRACT <br /> 04 <br /> Owner's Name �,u¢� [/ .' Phone 3 <br /> Address O „Cis_ City <br /> Contractor.'s Name _ �J „ . „ __ License.., Phone-?( :)er-J 7-2L <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN /7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR-/ / PUMP REPLACEMENT <br /> Other <br /> �. <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 Cable Tool Dia. of Well Excavation , . <br /> Domestic/private Drilled Dia. of Well Casing Via. <br /> Domestic/public Driven Gauge of 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: Contractor r ' <br /> .. _.._Type. of. Pump H.P. .r <br /> PUMP REPLACEMENT: -F<7 State=Work Done <br /> PUMP .REPAIR: /7 State Work Done <br /> r <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 pe <br /> rtaining 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 IN <br /> PRIOR TO-GRO G AND A EIML INSPEL%ION. <br /> SIGNED TITLE <br /> W.: PLAN 'ON rtSE SIDE -71 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY US DATE f- <br /> ADDITIONAL COMMTS <br /> PHASE II GROUT INSPECTION '-­PF1A'SL�,IIY FINAL INSPECTION '- <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> x/76 <br /> E H 1426 Bev. 1-74 : 2k,: <br /> �, <br />