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aa � <br /> I 'r 3 SAN JOAQUIN LOCAL HEALTH DISTRICT T <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 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 �1 ,S` S --" <br /> I CENSUS TRACT } <br />' Owner's Name { <br /> Phone <br />! Address <br /> Contractor's Name CityF <br /> License �fMhone <br /> 1 <br />, TYPE OF WORK (Check) : NEW WELL I I DEEPEN '/—/ RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / /= PUMP REPAIR <br /> / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY f <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 Industrial Cable Tool "'' } Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public 1 Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal <br /> Qther Other Information <br /> Geophysical <br /> 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 T- <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 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 />'RIOR TO GRO TIN9 AIJD A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDEj" <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> ' <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: f <br /> PHASE II GROUT INSPECTION P S /FI INSPECTION <br /> INSPECTION BY DATE INSPECTION B DATE <br /> E H 1426 Rev_ 1-74L : 1 /77 9M <br />