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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: : 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �� <br /> THIS PERMIT EXPIRES 1 YEAR FROM'DATE ISSUED . , Date Issued <br /> 11 , (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 /> i <br /> JOB ADDRESS/LOCATION J e CENSUS .TRACE <br /> Owner's Name Av, ,%A 42 %4za <br /> Z& - -�- Phone_ <br /> Address Z8City L134 e-4 <br /> Contractor's Name License /� i4 <br /> r <br /> TYPE OF WORK (Check) ; NEW WELL DEEPEN '/ / RECONDITION 1-7 DESTRUCTION /� <br /> PUMP 'INSTALLATION S?/'—PUMP REPAIR /—/ 7-PUMP REPLACEMENT /7 <br /> Other <br /> r <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD - . CESSPOOL/SEEPAGE PIT OTHER <br /> PROPER -- <br /> TY LINE PRIVATE DOMESTIC`WELL PUBLIC_ DOMESTIC WELL <br /> INTENDED USE TYPE OF -WELL CONSTRUCTION SPECIFICATIONS <br /> � I <br /> Industrial Cable Tool .� Dia. of Well Excavation p <br /> 'Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of CasingI 41k <br /> Irrigation Gravel Pack Depth of Grout Seal C <br /> Cathodic Protection Rotary ,_ Type of Grout �,,,,,� <br /> Disposal Other Other Information T <br /> Geophysical Surface Seal Installed By: <br /> i <br /> i <br /> PUMP INSTALLATION; Contractor � <br /> Type .bf Pump H.P. <br /> PUMP REPLACEMENT: / / ;',State Work Done i <br /> PUMP .REPAIR: / / ,;State Work Done <br /> DES'�RUCTION OF WELL: Wel] Diameter Approximate De th �Q <br /> Describe Material and Procedure/ L � <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local health District 1 <br /> and the State of Californial:pertaining to or regulating well"construction. Within FIFTEEN DAYS i <br /> after completion of my workI,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 FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FO DEPARTMENT USE ONLY �� (4s✓n� <br /> PHASE I <br /> APPLICATION ACCEPTED BY " s DATE <br /> ADDITIONAL COMMENTS: LLg <br /> PHASE II GROUT INSPECTION PHAS I I/FINAL INSPECTION <br /> INSPECTION`BY DATE INSPECTION BY DATE <br /> Oov <br />�., E H 1426 Rev. . l-74, <br /> o, 1�' _2M <br />