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SAN JOAQUIN LOCAL HEALTH DISTRICT ; <br /> FOF::OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone:. ' (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP-PERMIT Permit No.'•2±e/cy�D <br /> THIS PERMIT. EXPIRES 1 YEAR FROM DATE ISSUED Date. Issued <br /> (Complete In Triplicate) <br /> Application is hereby madetto 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. 18 and,the Rules/and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LO N11-r4CENSUS TRACT <br /> Owner's Named Phone <br /> Address �GC-CSL/ - City. dig P;2 <br /> Contractor's NameO& Licensea�3hone <br /> TYPE OF WORK (Check): NEW WELL/-7 DEEPEN /_7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION '[ -/,, PUMP REPAIR'? PUMP REPLACEMENT- /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> 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 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> F Cathodic Protection Rotary Type of Grout , <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY <br /> PUMP INSTALLATION: Contractor c� <br /> Type .of Pump , H.P. <br /> PUMP REPLACEMENT: . /7 State Work Done <br /> PUMP :REPAIR: //"�` :State Work Done I� <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''construetion. Within FIFTEEN DAYS <br /> after completion of my work .on a new well, I will�'furnish the.San.Joaquin' Ldcal Health District a <br /> WELL-DRILLERS REPORT of the well and notify them before putting the-wel1. in.use.... The above <br /> � information is true to the-best-of my knowledge and belief. . -.I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO G U ING AND A FINAL INSPECTION <br /> SIGNED _ Y� , ILI) TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> ' PHASE I <br /> APPLICATION ACCEPTED BYf DATE '__r, .�_ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASEII FINAL INSPECTION <br /> ' INSPECTION BY DATE INSPECTION BY DATE - -2 <br /> E H 1426 <br /> a <br /> Rev. 1--74 - -- --h/75 2M_ 1 <br />