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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelten Ave. , Stockton, Calif. 4e;4/1-p- dl <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /- '7 ! <br /> (Complete In Triplicate) <br /> Application is her � 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 /> v�- S� 5 I` �`OU(/7 *AENSUS TRACT <br /> JOB ADDRESS/LOCATION . '� <br /> Owner's, Name ��= ��F�.i /LF Phone �3tf" 2 O Z <br /> I <br /> Address S City <br /> yb� �Phone <br /> Contractor's Name License # <br /> TYPE OF WORK.'(Check) : NEW WET.T /WT- T)'PFJW _ CONDITION. / / DESTRUCTION /_7 <br /> +PUMP INSTALLAT'ZON / PU REPAIR / 7" PUMP REPLACEMENT /_7 a <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY 47 <br /> _ SWAGE 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 5�rt <br /> Domestic/public Driven Gauge of- Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection x Rotary Type of Grout o <br /> Disposal Other Other Information ..5(_A�B <br /> Geophysical rface Seal Installed By : <br /> P INSTALLATION: Contractor Ne ` <br /> Type of P mp H.P. 3 _ <br /> PUMP REPLACEMENT:- / / St to Wo-I- <br /> S <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> r Describe : Material and Procedure , _ w <br /> I hereby.,. gree 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 ;furni.sh the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify 'them before putting - thewell 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 GPOUTINC AN FINAL INSPECTION. <br />'SIGNED TITLE 5 <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I . r <br /> APPLICATION ACCEPTED BY LA, �\ DATE <br /> ADDITIONAL COMMENTS: <br /> TION <br /> PHASE II GROUT ,-.INSPECTION P S /FIN INSPECGROUT ,-.INSPECTION <br /> INSPECTION BY DATE f INSPECTION BY DATE <br /> E H 1426 Rev-1-74 <br />