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' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORI'OFFICE USE: / 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2,7- � <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 /> j JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name i v Phone <br /> Address _ ( ✓ City <br /> Contractor's Name License f"A_7Wj0'Phone <br /> TYPE OF WORK (Check): NEW WELL /� DEEPEN '/� RECONDITION /� DESTRUCTION f <br /> PUMP INSTALLATION I PUMP REPAIR /_7 PUMP REPLACEMENT <br /> Other / / ''�/ . a►"l-e! ?✓ <br /> I 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 TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> I� Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing x <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal 6 <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> -Geophysical Surface Seal Installed By: <br /> R G <br /> 1 PUMP INSTALLATION: Contractoroll / iS� _ ., <br /> Type of Pump H.P. <br /> I PUMP REPLACEMENT: /7 State Work Done <br /> PUMP :REPAIR: /_7 State Work Done <br /> &ESTRUCTION 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 /> PRIOR TO GROUTING ANDA IN SPECT ION. , <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY QDATE _ <br /> ADDITIONAL COMMENTS: <br /> PHASE iT GROUT INSPECTION P I NAL INSPECTION <br /> INSPECTION BY DATE a INSPECTION BY DATE <br /> fI µE H 1426 Rev. 1-74, 1-74 2M <br />