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o <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR,OFFI.CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;W_ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 337* , <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 ADDRESS/LOCATION �,�. CENSUS TRACT 7 <br /> Owner's Name Phone <br /> Address 7 City S <br /> w , <br /> Contractor's Namef <br /> O License #CxZ9W Phone <br /> f z <br /> ,TYPE OF WORK (Check)`: NEW WELL l=T DEEPEN /-7 RECONDITION /7 DESTRUCTION %j s <br /> PUMP- INSTALLATION /_/ PUMP REPAIR 0 PUMP REPLACEMENT f7 <br /> Other <br /> r. <br /> DISTANCETONEAREST: ISEPTIC TANK SEWER LINES FIT PRIVY ,. <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT: OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC'•DOMESTIC WELL W <br /> INTENDED USE TYPE OF WELL CONSTRUCTIONiSPECIFICATIONS AJ ! <br /> Industrial Cable Tool Dia. of Well Excavation°' <br /> Domestic/private f. Drilled Dia. of Well Casing, <br /> Domestic/public: brfven i`� #, �` Gauge of Casing I : <br /> Irrigation ,` Gravel Pack `Depth of Grout Seal + <br /> Cathodic Protection,. ... . Rotary---- e--of�..Grout`""�'°""" -� <br /> _�._._.� _Typ . <br /> Disposal §-. R, i� Other i s� ;0ther' Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: 1, Contractor.: <br /> Type of Pump . . �. sx ) H.P. <br /> PUMP REPLACEM'ENTI / State Work Do t <br /> j <br /> . . r <br /> a ..�fi . - - - - <br /> PUMP`'REPAIR: '"` ` State ,& <br /> ....,._.,._ r �Work Done r.i <br /> a <br /> E&TRUCTION 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 thein before putting.the..well in use.. The above- <br /> information is true tolthe-best-of my knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR T'O G ING AND A H4,INSPECTION. <br /> SIGNED TITLE i <br /> DRAW PLOT PLAN ON REVERSE SIDE i <br /> D T' USE ONLY 1 <br /> PHASE I I <br /> APPLICATION ACCEP t <br /> DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTIO DATE - <br /> . 1 F <br /> E H 1426 Rev. 1-74 1-74 2M <br />