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y ]U' SAN JOAQUIN LO ALTH DISTRICT <br /> FOR 0MP� .,USE: " 1601 E. Hazelton Ave, , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> I` APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ZA.5 3 k) <br /> Y THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued,2 Lg-_V <br /> 4 1 <br /> (Complete In Triplicate) <br /> Application is Aereby 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 t e Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION _ CENSUS TRACT <br /> Owner's Name Phone � <br /> Address City �t i d�ini <br /> Contractor's Name lf4 -License 0 12h Phone <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /_7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTAL TION J / PUMP REPAIR / / PUMP REPLACEMENT /7 <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 Dia. of Well Casing �1 a <br /> Domestic/public Driven ;-_Gauge of -Casing� - <br /> Irrigation Gravel Pack Depth of Grout Seal Oil---�. <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal a Other Other Information _ <br /> Geophysical. a" Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 'r <br /> Type of Pump R.P. . . - <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP -REPAIR: / J State Work Done a <br /> F <br /> DESTRUCTION OF"WELL.: Well Diameter Approximate Depth ' <br /> Describe Material and Procedure - <br /> l <br /> ` I hereby agree to comply with all laws and regulations of the San Joaquin Local Health .iWtrict <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 4NAL INSPECTION. <br /> SIGNED TITLE a <br /> W PLOT PLAN ON REVERSE SIDE <br /> k FOR DEPARTMENT USE ONLY �B <br /> PHASE i p� <br /> APPLICATION ACCEPTED BY DATE <br /> i ADDITIONAL COMMENTS: f <br /> " IIGROUT INSECTION ETPHASEf II <br /> INSPECTION BY al <br /> DATE INSPECTION BY DATE " c <br /> E H ,1426 Rev. 1-74 '� <br />