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k <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOB OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 6 <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 /> CENSUS TRACT <br /> Owner's Name , Phone <br /> Address 7 <br /> City <br /> Contractor's Name License #I22373 PhoAe3�,�.5:�'3�,. <br /> TYPE OF WORK (Check) : � � i f` <br /> { NEW WELL �/7 DEEPEN '/� RECONDITION �/ 7 DESTRUCTION /7 <br /> PUMP INSTALLATION J / PUMP REPAIR PUMP REPLACEMENT j <br /> Other E7 -- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY s <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE J PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> j INTENDED USE ITYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing f <br />'f 'Doutestic/public _: - -Driven "1° Gauge--of Casing. ° ---L—' <br /> Irrigation. . Gravel Pack- Depth of Grout .Seal <br /> Cathodic Protection Rotary Type of Grout ' _ <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Tristalled B <br /> PUMP INSTALLATION: Contractor <br /> .Type of. Pump It' ; . H.P. <br /> PUMP REPLACEMENT: E7 State Wo4, Done <br /> PUMP,.REPAIR: � Sti te'Work�Done <br /> DESTRUCTION OF WELL: Well, Diameter ApproximatefDepth <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' pertainini to or regulating well -'construction. Within FIFTEEN DAYS <br /> after completion of my work on a new 4ell, 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. - 1 WILL CALL ,FOR A `GROUT INSPECTION , <br /> PRIOR TO GROUTINGAN A VOW INSPECTION. E <br /> SIGNED TITLE �'" , <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> ' FOR DEPARTMENT USE ONLY <br /> PHASE I } ; <br /> APPLICATION ACCEPTED BY - DATEi' �}/� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS I AL INSPECTION. <br /> INSPECTION BY DATE INSPECTION BY DATE _-7 � <br /> E H 1426 Rev. 1-74 h/75 .2M <br />