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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r° 'FOArOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 t <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. f <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> 4plication 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. e /7/ 12 `3, ���1,�[.�� .—. CENSUS TRACT <br /> Owner's Name �._ �1 c�Lc � 1 �y7/� PhoneS - <br /> Address dyl Cit <br /> Contractor's Name License Phone <br /> " TYPE OF WORK (Check):NEWVELL/7 DEEPENS'7—RECONDiTION-/7—DESTRUCTION /7 <br /> PUMP I ST LATION L7 PUMP PAIR ` PUMP:REPLACEMENT / <br /> Other 7. <br /> k <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> .1 ; , SEWAGE DISPOSAL FIELD t . CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL - PUBLIC DOMESTIC WELL <br /> INTENDED .'USE- , N, STYPE-OF WELL . .- CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool € Dia. of Well Excavation �! <br /> Dome itic/private - Drilled Dia. of Well Casing <br /> Domes tic/public;N _jr Driven Gauge of Casing <br /> # Irri atian r Gravel Pack "!Depth of Grout Seal <br /> l Cathodic Protection Rotary ., Type of Grout <br /> : <br /> Disposal Other Other Information <br /> Geophysical. 'Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor : <br /> Type of Pump. H.P. <br /> PUMP REPLACEMENT: / ./ S tate. Work Done <br /> 'PUN .REPAIR.- 'Stafid Work Dobe `""� �`. '- -'• - 'i <br /> t <br /> {?ES�TRUCTION OF+,WELL:_,-.,.Well,.Diameter Approximate Depth <br /> - Describe Materia4nd 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 AND A FIaAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY !Uu- t9 DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS I//FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br />� y1 E H 1426 Rev. 1-74 1-74 2M W <br />