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r SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> k .� <br /> i FORrOFFTCE USE: x 1601 E. HazeltonAve , Stockton, Calif. <br /> n.: Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT WIRES 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 ADDRESS/LOCATION �l� 2 Xr CENSUS TRACT <br /> Owner's Name e- Phone <br /> ;Address" � � Y I'` ' City <br /> Contractor's Name is nse #3&T9 Phone S-22-16 l <br /> TYPE OF WORK (Check): NEW WELL ',M, DEEPEN /T' RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR /7 PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK&LOSSEWER LINES PIT PRIVY. <br /> SEWAGE DISPOSAL FIELD ",CESSPOOL/SE9PAGE PIT OTHER <br /> PROPERTY LIFE La <br /> PRIVATE DOMESTIC' WEL ' "1. PUBLIC DOMESTIC WELL <br /> F INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> t Industrial Cable Tool Dia. of Well EkcaVation <br /> € Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type-of-Grout' f <br /> Disposal : .Other Other Informatio ' <br /> Geophysical Surface Seal Installed B : <br /> PUMP INSTALLATION: Contractor,' <br /> Type of Pum H.P. <br /> E <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP�REPAIR: /7 State Work Done - <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 StateNof 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 /> f information is true to the-best of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROFTMG AND A FINAL Ia CTION. -- <br /> SIGNED TITLE <br /> —� rf (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR ,DEPARTMENT USE ONLY <br /> PHASE, I x <br /> APPLICATION ACCEPTED BY DATE <br /> o <br /> ADDITIONAL.COMMENTS: l / - ex" <br /> P 5E I GROUT INS CTION PHASE III FINAL INSPE ION <. <br /> r INSPECTION BY DATEINSPECTION BY <br /> 7_p DAT <br /> wE H 1426 Rev. 1-74 ' 1-74 2M <br />