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'_PSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> _L9%!.OFFICE USE: 16 01 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 - <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. fir _ S�pA) <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 Joaquin, <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. , <br /> JOB Ad-,,T7ot CENSUS TRACT <br /> Owner's Name "` Phone <br /> Address cJ G-� G�, <br /> City <br /> Contractor'sName � G) License /Phone , ///' <br /> TYPE ;OF WORK (Check):—NEW IWELU <br /> /DEEPEN.`/ "RECONDITION ./?-_-DESTRUCTION'/. j'"" <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /j <br /> Other / / -- <br /> DISTANCE TO NEAREST:. SEPTIC TANK '- SEWER LINES PIT PRIVY <br /> fi� 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 Casing­7-.�=- - -- <br /> Irrigation Gravel. Pack Depth of Grout Seal <br /> Cathodic Protection !/ Rotaryf <br /> Type of Grout <br /> Disposal Other Other Information <br /> GeophysicalSu`rf's a Seal Installed B <br /> PUMP-INSTALLATION: Contractor <br /> a Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'REPAIR: /7 State Work Done - <br /> ry _ -_ <br /> E&TRUCTION-OF•WELL: Well''Didmeter `"' � � 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 PROUTING AND A XINAV INSPECTION: <br /> SIGNED ( �y �,/ TITLE <br /> V 1 (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> - <br /> APPLICATION ACCEPTED BY � . DATE '/la P1 Y T <br /> ADDITIONAL COM ENTS: ' <br /> PHASE I GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY ,� DATE D``�� INSPECTION. BY DATE A/ ;2_ 7 <br /> T <br /> 1 1~E H 1426 `. Rev. Z-74 <br />