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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i <br /> FOK OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> _ Telephoner (209) 466-6781 <br /> �3t� APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Na. ,�.r' <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 appXication is made in compliance with San Joaquin! <br /> County Ordinance No. 1862' an1' theRules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION v CSL I� CENSUS TRACT <br /> Owner's Name Phone ' 3/--L�2 11 <br />. Address. `E?--_ " <br /> _ . City ' <br /> Contractor's Name G' ,� License ! Phone <br /> I <br /> TYPE OFgWORK {Check}:`h'--NEW WELL -/ IDEEPEN /7 RECONDITION F7 DESTRUCTION <br /> PUMPINSTALLATION J / PUMP REPAIR '/� PUMP'REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> s - SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ► ' , <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC.-DOMESTIC,WELL <br /> -, INTENDED-USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> 'Industrial Cable Cable Tool Dia. of Well Excavation � . <br /> _wDomestic/private' Drilled Dia. of Well Casing i <br /> Domestic/public s Driven Gauge of Casing <br /> Irrigation Gravel Pack . Depth of Grout Seal <br /> Cathodic Protection: , „ Rotary Type of Grout <br />` Disposal. Other u Other Information <br /> --Geophysical Surface Seal Installed 'By: <br /> PUMP INSTALLATION: ` <br /> . Contractor - <br /> Type .of Pump. H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP :REPAIR: / / .State Work Done , <br /> DESTRUCTION OF WELL: Well Diameter <br /> ' Approximat Depth 6-5 <br /> Des c ibe Mater 1 and rocedure <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 /> informatiod is true to the-best-of my knowledge and belief. I WILL CALL -FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING D A F N INSPECTION. <br /> SIGNED ✓ri. TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT--USE-ONLY.- <br /> PHASE I ' <br /> APPLICATION ACCEPTED BY s� DATE `:�) <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPeCTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev: 1:-74 r ��_� !x/75 2M <br />