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y SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209)' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�� �! <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �� <br /> (Complete In Triplicate) <br /> Application is h+ereby 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/LOCATIONQ �f CENSUS TRACT <br /> Owner's Namec3`7 <br /> Phone <br /> Address City <br /> Contractor's Name _ License I��o �f�phone 2?17 <br /> / <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN /_% RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK _16Er SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL MELD 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 /> y 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 X Rotary Type of Grout <br /> Disposal. Other �� Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor _ <br /> Type of Pump / H.P. �r <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,REPAIR: /-7 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 well 'construction, Within FIFTEEN DATS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT o he well and notifythem before The above <br /> putting the well in use.. <br /> information is true o t e,_•].St of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO D A FIN IN ECT ION. <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: --- <br /> P UT INSPECTION PHW I INAL INSPECTION <br /> INSPECTION BY DATE �� - INSPECTION BY DATE 3 -- 2 3-22 <br /> r _77- <br /> .ti <br /> E H 1426 ev. 1-74 117.7 j7 .. 2M <br />