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SAN JOAQUIN LOCAL HEALTH DISTRICT - v <br /> FOSrOFFICE .USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION'FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. P�a- Y1 <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 Joaqui4 <br /> County Ordinance No. . 1862 and the Rules 'and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION %' r ­CENSUS. TRACT <br /> Owner's Name /1 412 �" T u Phone d b 7 <br /> Addresscity <br /> / <br /> '" 7/` •c <br /> Contractor's Name <br /> 21- 7 License �;Zd�Phone �� Y <br /> ,..-- <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN /_7 RECONDITION /7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMA' REPAIR ./—/ PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> .F SEWAGE DISPOSAL FIELD. CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL , CONSTRUCTION, SPECIFICATIONS <br /> Industrial _� Cable Tool --Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 12 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection--! , Rotary Type of Grout' G j <br /> Disposal. -Other Other Information <br /> Geophysical -Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> i PUMP REPLACEMENT: / / State Work Done - <br /> k <br /> PM .REPAIR; /? State Work Done <br /> UCTION OF WELL: Well Diameter <br /> j �ES.TRW <br /> —�. 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 R TI D A F AL._ SPECTION. <br /> SIGNED TITLE y <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR: DEPARTMENT USE ONLY <br /> PHASE I ,...., <br /> APPLICATION ACCEPTED BY too, DATE0 <br /> ADDITIONAL COMMENTS: TT <br /> PHASE II GROUT INSPECT ON PHASE III FINAL INSPECTION <br /> -.-- A , <br /> INSPECTION BY i DATE !� INSPECTION BY . DATE <br /> - r <br /> 1 _E H 1426 Rev. 1-74� �� 1-74 2M <br />