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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORIOFFICE USE: 1601 E. Hazelton 'Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. al ; <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 -` = CENSUS TRACT <br /> Owner P s Name * v�� l - `% /'I I� Phone <br />' Address �Q - City <br /> s <br /> -Contractor's Name C 1,4 1AZr License # 7G 602 Phone Y42-S <br /> TYPE_OF-WORK..(Che ck): .NEW WELL-/,T--DEEPEN,'17•-.RECONDITION&-r DESTRUCTION f7- <br /> PUMP <br /> 7-PUMP INSTAM�ATION'�' /PUMP REPAIR /_7 PUMP REPLACEMENT %f i <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 <br /> Industrial '' Cable Tool Dia.;'of Well Excavation <br /> Domestic/private Drilled Diai. of Well Casing <br /> Domestic/public 4 Driven Gauge of Casing <br /> L Irrigation -, gavel Pack Depth of Grout Seal .A <br /> Cathodic Protection- Rotary Type of Grout <br /> t <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B' <br /> PUMP INSTALLATION: Contractor a` <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: I <br /> State Work Dane# <br /> i i <br /> PUMP :REPAIR: ' - } <br /> . L� State Work Done r _. <br /> ES;TRUCTION OF WELL: Well 'DiameterApproximate Depth <br /> Descfibe Material and Procedure <br /> I hereby agree to comply with'-all 1aws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining-'to or regulating well construction. Within FIFTEEN DAYS 1 <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 TIG AND A FINAL INSPECTION. w <br /> SIGNED [ TITLE <br /> F (DRAW PIAT PLAN ON REVERSE SIDE) <br /> F R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 11 <br /> ADDITIONAL COMMENTS: �. 3 <br /> PRASE II GROUT INSPECTION PHASE III FINAL INSPECTION k <br /> INSPECTION BY ? DATE INSPECTION BY DATE /ZF-/, 7. <br /> ti <br /> E H 1426 Rev. 1-74 1-74 2M <br />