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SAN JOAQUIN LOCAL HEALTH DISTRICT 0sr, /X <br /> SOF OFFICE USE: . 160.1 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <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 �� <br /> 01 CENSUS TRACT � <br /> Owner's Name . p y Phone 44 <br /> Address /! 1 City <br /> Contractor's Name , yra a „Q License # Phone Y,/,yo- <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/_% RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION /�.�- PUMP REPAIR / / PUMP REPLACEMENT /- <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 Cable Tool Dia: of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <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 a ,L v i,, 42 <br /> Type of Pump ;r H.P. <br /> PUMP REPLACEMENT: / / State Work Done l�► <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth r <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.,,Dis.tri.ct 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 GROUTING D A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR ,DEPA4TMENT USE ONLY <br /> PHASE I <br />., kPPLICATION ACCEPTED BY DATEo2� <br /> ADDITIONAL. COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTIOIJ <br /> INSPECTION BY DATE INSPECTION BY DATE 3 / <br /> E H 1426 Rev. , 1-74 0/77 _ 2M <br />