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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> =F, OFFICE USE: .1601 E. Hazelton Ave. , Stockton, Calif. <br /> j 7z Telephone : (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> E <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.per.mit to construct <br /> and/or,.instal.l the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 62 ye <br /> ule and Regulations of the San Joaquin, Local Health District. <br /> JOB ADDRESS/LOCATION , Gvj `f CENSUS TRACT <br /> Owner's Name Phoned <br /> Address <br /> City <br /> Contractor's Name License J/(,.2j)j_ Phone3ic <br /> TYPE' OF WORK (Check) : NEW WELL / / DEEPEN/_/ RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR 4!5 " PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY - <br /> SEWAGE DISPOSAL FIELD CESSPOOQSEEP-AGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC-WELL-�F PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL . ' CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool __---� Dia, of Well Excavation <br /> i <br /> Domestic/private Drilled` Dia. of Well-"Casing <br /> Domestic/public , .Driven Gauge o <br /> g of. Casing <br /> �., � _ <br /> Irrigation�-`—'�"` r�G'r�velTPack—Depth of Cr8up Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: T <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. f�— <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: 4W 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 wel.l 'constructi.on. 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 i true to the est of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO NG D A,ZJ,4KL INSP TION. <br /> SIGNED TITLE <br /> W PLOT PLAN ON REVERSE SIDE) <br /> t FOR DEPARTMENT USE ONLY <br /> PHASE I !. <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: i <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION : <br /> INSPECTION BY DATE INSPECTION BY C� DATE 7- ,x.S- <br /> 6/77 2M <br /> E H 1426 Rev. - I-74 <br /> . <br />