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;X. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> k FM OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELT., CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 7 THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> k ('Complet'e'- In Triplicate) _ <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct <br /> and/or install the work herein described. This .application is made in compliance with San- <br /> 'Joaquin <br /> County Ordinance No-. 1862 .and the Rules and ,Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �,� . /} //.� , � i � _ _fK CENSUS TRACT' <br /> ,may {.. . ' • - <br /> ' Phone <br /> Owner's Name <br /> Address <br /> city <br /> Contractor's Name License <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN '/ / RECONDITION / / DESTRUCTION <br /> PUMP INSTMATION / / PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK X 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 /el;} iI <br /> Domestic/private Drilled Dia. of Well Casing if <br /> Domestic/public Driven Gauge of Casing f2254za�- <br /> r Irrigation Gravel Pack Depth of Grout Seal <br /> tet— Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: _ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P ' <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMp .REPAIR: / / State Work Done <br /> DES•TRUCTION -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 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 thewell 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 AND A .FINAL INSPECTION. <br /> SIGNED TITLE <br /> OT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY GU DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 2M <br /> E H 1426 Rev. - l-74 <br />