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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS'OFFICE USE: 1601 E. Hazelton Ave.., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> 3 - APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7/, <br /> L <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 7/,z Phone Phone 3Address S % �' , . �� z City <br /> Contractor's Name L ' '� � y License VELL,2phone <br /> TYPE OF WORK (Check) : NEW WELL /DEEPEN /7 RECONDITION /-7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR /-7—PUMP REPLACEMENT IU- <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 �1 <br /> industrial able Tool Dia. of Well Excavation ?I <br /> :f Domestic/private Drilled Dia. of Well Casing <br /> _ Domestic/public Driven Gauge of Casing Q- <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout '.,de�c. <br /> Disposal Other Other Information <br /> Geophysical Surf ate Seal Installed By: e-,�fzj%:` IN <br /> PUMP INSTALLATION: Contractor .c��� <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done +ri'48 <br /> PUMP :REPAIR: /7 State Work Done <br /> JpES•TRUCTION OF WELL: Well Diameter Appro mate Depth <br /> Describe Material and Procedure1' <br /> -cam <br /> I hereby agree to comply with all laws and eegulations 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 GROy7jNG AND A, FINAL INSPryCTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> AIPLICATION ACCEPTED BY C= (3.Q DATE <br /> ITIONAL COMMENTS: T <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTIpN /�� <br /> INSPECTION BY DATE INSPECTION BY DATE to <br /> E H 1426 Rev. 1-74 1-74 2M <br />