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I � <br /> ;> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. V— fg <br /> i Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Permit No. ` 3 6/p <br /> I! <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby . de 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 Joaqui <br /> County Ordinance No. 1'$62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION J, 7 0a2:. mlloctrhoG CENSUS TRACT <br /> ! Owner's Name 0 Phone . <br /> I` . <br /> r Address City, <br /> F <br /> Contractor's Name is License UPhone <br /> t <br /> TYPE OF .WORK (Check): NEW .WELL j_T DEEPEN _ RECONDITION DESTRUCTION f 7 <br /> �IPiTMP'''INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT 17 <br /> Other <br /> r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSP00L/SEEPAGE PIT OTHER <br /> PROPERTY LINE -_PRIVATE DOMESTIC WELT.' PUBLIC DOMESTIC WELL \ <br /> INTENDED USE I . TYPE OF WELL CONSTRUCTION SPECIFICATIONS; O <br /> ndustrial Cable Tool Dia. of Well Excavation <br /> Dot stic/private' Drillea Dia. of Well Casing <br /> Domestic/public' Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout SealKOK C_ Ar !' <br /> Cathodic Protection Rotary Type of Grout 41V <br /> k Disposal I "I Other Other Information <br /> Geophysical ASurface Seal Installed By:' <br /> PUMP INSTALLATION: Contractor <br /> Type of,Pump fl . <br /> H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP +REPAIR: (�/ / State Work Done <br /> p . } <br /> DESTRUCTION OFyWELL ..Well Diameter Approximate Depth <br /> r I�Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin'Local Health,Distiict <br /> i and the State of California pertaining to or regulating well •'constructi.on: Within FIFTEEN_DAYS <br /> I after completion of my :work on a new well, I will furnish the San Joaquin Local Health',District <br /> WELL DRILLERS REPORT otl' the -well and notify them before putting the .well. in.use-.T.". <br /> The above <br /> information is true to '.the-best-of'my..knowledge and 'belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING -MD k NAL INSPECTION: <br /> SIGNED �' • _ TITHE - <br /> !h (DRAW PLOT PLAN ON .REVERSE SIDE)— ._ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I I� <br /> APPLICATION ACCEPTED BY: DATE ' <br /> ADDITIONAL COMMENTS: �I - <br /> PHASE II G:. UT INSPECTI y PWASV, III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 1426 Rev. 1-74. L/7K 9M <br />