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{ SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> FOH.OFFICE USE: VVV 1601 E. Hazelton Ave. , Stockton, Calif.- <br /> Telephone : -(209): 466-6781 '7 7P k, <br /> APPLICATION FOR. WELL CONSTRUCTION OR PUMP PERMIT Permit No, <br /> THIS PERMIT EXPIRES l YEAR FROM DATE 'ISSUED Date Issued F7 <br /> (Complete In Triplicate) , m f7-110 -f7 <br /> Application is hereby made to the San Joaquin Local, Health Ditrict for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaqui <br /> County Ordinance 'No. :,1862 and -the Rules and Regulations of the. San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> f <br /> Owner's Name ` <br /> �r�� Phone <br /> Address City <br /> Contractor's Name �/✓/7/ j j /,�,�j License Phone, 9- <br /> . TYPE <br /> -. TYPE OF WORK (Check) : NEW WELL%. DEEPEN / /. RECONDITION /_/ DESTRUCTION /_ <br /> PUMP INS ALLATION K/ 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 TYPg OF WELL CONSTRUCTION• SPECIFICATIONS 1 <br /> Industrial 1 Cable Tool. Dia, of Well Excavation � � � <br /> Domestic/private Drilled Dia. of Wel-I Casing t <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 f �. <br /> Geophysical Surface Seal Installed By: <br /> PUMP. INSTALLATION: Contractor <br /> Type. of Pump H.P. f' <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: �.� <br /> / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter. Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comp-ly 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 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 GROU. IN , AND A`FIN SPE CT ION.,. <br /> SIGNED ,.� i TITLE <br /> _(DRAW PLOT..PLAN ON REVERSE SIDE <br /> PHASE I FQjZ DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE r�' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTI N: <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 . 1177 _ 2M <br />