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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOB OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. 1 <br /> Telephone: (209) 466•-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. pZZd <br /> �6-f2 map <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> s. (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> i 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 /> - <br />`, JOB ADDRESS/LOCATION r CENSUS TRACT X d 7- <br /> Owner's Name - Phone �fes' ' <br /> Address V E City _-1=64 <br /> r <br /> Contractor's Name License Phone?/ <br /> TYPE OF WORK (Check) : NEW WELL /"-DEEPEN '/_T RECONDITION /_]` DESTRUCTION !I <br /> PUMP INSTALLATION / / PUMP REPAIR /�-PUMP REPLACEMENT. %T <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 TYPE OF WELL CONSTRUCTION SPECIFICATIONS (v <br /> Industrial Viable Tool Dia. of Well Excavation \ <br /> Z-�O astic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal ""'Idev <br /> Cathodic Protection Rotary Type of Grout ` d? �' _ ^ <br /> Disposal Other Other Information <br /> Geophysical. Surface Seal Installed 'B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump d! H.P. <br /> PUMP REPLACEMENT: .. / / State Work Done <br /> PUMP ,REPAIR: / / State Work Done <br /> , DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> j I hereby agree to comply with all ?yaws 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 GROIN AND A FINAL INSPE 0 . <br /> . SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) _--.-- <br /> F04, DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY C �- DATE 'S � <br /> ADDITIONAL COMMENTS: <br /> t. PHASE GROUT INSPECTIO PHASE It FIN INSPECTION <br /> INSPECTION BY DATE % �t y-7G . INSPECTION BY DATE <br /> -"'" <br /> E H 1426 Raw- 3-74 - <br /> �- --- - _ 4175- - �"t <br />