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SAN JOAQUIW LOCAL HEALTH DISTRICT <br /> IFOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif, <br /> # Telephone : (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No-, <br /> THIS. PERMIT EXPIRES I `YEAR FROM DATE ISSUED Date Issued._<'--,/S.. <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin, Local Health District for a permit to construct <br /> F and/or .install the,work herein described. This application is made in compliance with San Joaqui <br /> County Ordinance No.. 1862 and the. Rules anal Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS{ - 'ed NSUS TRACT <br /> i Owner's Name Phone <br /> Address _ City <br /> Contractor's Name License A.PM& Phone /-'3zlL <br /> TYPE OF WORK (Check) : NEW WELL / ( DEEPEN /% RECONDITION / / DESTRUCTION /7 �/ <br /> PUMP INSTALLATION PUMP REPAIR /—/7-PUMP REPLACEMENT /_7 <br /> Other <br /> r DISTANCE TO NEAREST: SEPTIC TANK -SEWER LINES -PIT PRIVY <br /> SEWAGE DISP S ktIELD /�Oy <br /> CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINWe iRIVATE DOMESTIC WELL,/_L0_49 q"PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation LIf <br /> 1_�omestic/privateylSrilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection -,=, Type of Grout j- <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 7/ ..S <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP '.REPAIR: / / State Work Done <br /> DES-TRUCTION 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 /> 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 INSPECTI N <br /> PRIOR TO GROUTING ANDAA FINAL INSPECTIU <br /> I{ SIGNED TIT E <br /> W P 0 P ON REVERSE IT. <br /> PHASE I <br /> - _,.�.. , ,, _ .,_,,,� FOR DEP TMENT USE ONLY <br /> - <br /> APPLICATION ACCEPTED BY DATE 5 h 5 7 <br /> ADDITIONAL COMMENTS: <br /> P ROUT INSPECT ON Q��+ PHA /F AL INSPECTI0 <br /> INSPECTION BY DATE y�Q INSPECTION BY DATE <br /> E H 1426 Rev- 1-74 n!77 _ 2M <br />