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i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> O-90FICE USE: ' 1601 E. Hazelton. Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. - �40/� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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/R�ules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION. [/l JI' � r��/`1 CENSUS TRACT <br /> Owner e s Name Phone <br /> Address � �d C� 1 o�j'G( /'. City Z&O <br /> q <br /> Contractor's Name 11- Q n License Phone <br /> y 1 <br /> TYPE OF WORK (Check): NEW WELL DEEPEN ,/-/, RECONDITION /.7 DESTRUCTION f F <br /> PUMP INSTALLATION / / PUMP REPAIR /% ' PUMP REPLACEMENT <br /> Other <br /> -- s <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY . <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATES.:DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE, TYPE O WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation=Do <br /> mestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge. of Casing _ l� <br /> Irrigation Gravel Pack Depth of Grout Seal, � <br /> Cathodic Protection Rotary Type of Grout 4.5dcl rT,,ea 7 / <br /> Disposal. Other Other Informatidn k <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pu <br /> yp 4 /Ni' 1' H:P. a <br /> k, <br /> PUMP REPLACEMENT: / / State Work Dane <br /> DUMP :REPAIR: f% .-State .Work Done <br /> E&TRUCTION OF WELL: Well Diameter _ Approximate Depth <br /> Describe Material and Procedure <br /> 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 14ETINC FIN INSRECTION. <br /> SIGNED TITLE a��� f� <br /> r (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PRASE 17 <br /> APPLICATION ACCEPTED Bf;z <br /> DATE <br /> ADDITIONAL COMMENTS: . <br /> PHASE II ROUT INSPECTION PHASE I Z INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE [. i <br /> bob .i <br /> E H 1426 Rev. 1-74 . <br /> 1-74 2M > ` <br />