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c <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 4) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issuec <br /> (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 /> JOB ADDRES ®,� 00, <br /> Zai0 CENSUS TRACT <br /> Owner's Name !l/[ T 1 (�� �� Phone <br /> Address city/ y . <br /> Contractor's Name -License /�WphoneP.�/-�sZ/� <br /> TYPE OF WORK (Check): NEW WELL DEEPEN/7 RECONDITION DESTRUCTION (7 - <br /> PUMP INST LATION 4J PUMP REPAIR _ <br /> /_7 PUMP REPLACEMENT <br /> Other / / . . <br /> DISTANCE TO NEAREST SEPTIC TANKeq SEWER LINESQ PIT PRIVY <br /> SEWAGE DISPOS OOL/SEEPAGE PIT Z yc-QTHER <br /> PROPERTY LINE IELD CESSPRIVATE DOMESTIC WELL " PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well ExcavationdeV <br /> Domestic/private Drilled Dia. of Well Casing xx �1\ <br /> Domestic/public Driven Gauge of Casing Z <br /> Irrigation Gravel Pack Depth of Grout Seal 1E F- <br /> Cathodic Protection Rotary Type of Grout � 2 <br /> Disposal Other Other Information-Geophysical Surface-Seal Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 194 rl"4*1g <br /> Type of Pump �f G H.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP '.REPAIR: /7 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 /> 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 TLE <br /> 3 DRAW PLOT PJAN ON REVERSE SIDE - <br /> a <br /> D TMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEP QO p DATE ' -/ <br /> ADDITIONAL COMMENTS: . <br /> PFV II G OUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY. DATE 5� INSPECTION BY DAT <br /> E H 1426 Rev. 1-74 _ h/75 2N. f <br />