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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FBF- OFFICE, USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> s 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 j-_/,�_�� <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. .}-j <br /> � � <br /> JOB ADDRESS/LN 0164,4- 4: v% QAV-6,4/7r7-7 CENSUS TRACT <br /> Owner's Name of Phone <br /> Address City <br /> Contractor's Name Pt. License Phone; <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN /_/ RECONDITION E/ , vDESTRUCTION I-T <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT /�­ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK drLQ SEWER LINES Q` PIT PRIVY .•�- <br /> SEWAGE DISPOSAL YIELD �' CESSPOOL/SEEPAGE PIT/Lld -f-OTHER <br /> PROPERTY LIN L RIVATE DOMESTIC WELL "PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL - CONSTRUCTION SPECIFICATIONS .� <br /> Industrial Cable Tool' - Dia. of Well Excavation <br /> Domestic/private K Drilled Dia. of Well Casing <br /> Domestic ublic <br /> /P Driven Gauge of Casing 2, <br /> Irrigation Gravel,Pack Depth of Grout Seal .¢-- <br /> Cathodic ProtectionRotary Type of Grout 0-- <br /> Disposal Other Other Information <br /> Geophysical <br /> Surface Seal Installed B <br /> ,-PUMP INSTALLATION: Contractor- ,r <br /> Type of Pump . H.P. <br /> ' I <br />-.PUMP REPLACEMENT: / State Work Done <br />-PUMPrREPAIR r <br /> .�_... ___ - -_/. /Y-=Sta-t-e�Work Dore <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 /> SIGNEDE <br /> L ON RE ERSE SIDE) 4 MIT li " <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION # <br /> INSPECTION BY �. DATE /2 R.2-3 -74 INSPECTION BY _ DATE *;2L , <br /> E H 1426 Rev. 1-74 376 2M <br /> x <br />