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SAN JOAQUIN LOCAL HEALTH DISTRICT n `� <br /> FOF- OFFICE USE: '1601 E. Hazelton Ave. , Stockton, Calif. I C L <br /> 'I Telephone : (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> T91S PERMIT EXPIRES 1 YEAR FROM DATE ISSUED " Date Issued <br /> (Complete In Triplicate) a <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. j <br /> I <br /> JOB ADDRESS/LOCATION CENSUS TRACT i <br /> Owner's NameG_J / -E� _ --- . ..--------- Phone <br /> Address i t y <br /> 1 <br /> Contractor's Name License #,,�, �Phone <br /> IF <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN '/ J RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <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 JYPE OF WELL CONSTRUCTION SPECIFICATIONS . <br /> Industrial Cable Tool Dia, of Well Excavation <br /> i <br /> Domestic/private Drilled Dia, of Well Casing ` <br /> Domestic/public Driven Gauge of Casing f�2 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection _ Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geo h sical <br /> P Y .'i 44 <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type ,of Pump H.P. ' <br />' PUMP REPLACEMENT: / / iFState Work Done <br /> PUMP .REPAIR: / / :!State Work Done <br /> DESTRUCTION OF WELL: Well '',Diameter Approximate Depth <br /> Describe Material and 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 />'E 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 GROU NG AND A FIN 'r INSPECTION. <br /> SIGNED TITLE <br /> if <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> 'PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: f6ld <br /> PHASE II GRCW REINSPECTION --'PHASE Kl�/FJNAL INSPECTION <br /> INSPECTION BY ;DATE INSPECTION BY DAT <br /> --E H_1426 Re-u- 1-74 'I ----. - 77 2M <br />