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SAN JOAQUIN LOCAL [HEALTH DISTRICT <br /> FOAiOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued !6/�r7 <br /> (Complete In Triplicate) I I . <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install thelwork herein described. This application is made in compliance with San Joaquin <br /> County Ordinance `No. 1862. and the Mules and Regulations of the San Joaquin ]Local Health District. <br /> JOB ADDRESS/LOCATION TSS TRACT <br /> Owner v s Na, e- 1� / � L Phone 'CVa '7 <br /> Address . py } <br /> Contractor's Name ��� License # � Phone % <br /> I, "TYPE OF WORK (Check): NEW WELLl? DEEPEN _ <br /> I7 RECONDITION /_� DESTRUCTION f7AL <br /> PUMP INSTLATION PUMP REPAIR /- /7"PUMP REPLACEMENT ' <br /> Other <br /> E "tr <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWERfLINES, PIT PRIVY S <br /> SEWAGE DISPOSAL FIELD ' CESSPOOL/SEEPAGE PIT a° OTHER Q <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL Ll <br /> INTENDED USE TYPE OF WELL , j 4 CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool ` Dia. 'of Well Excavation • <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 <br /> Disposal Other Other Information <br /> Geophysical � Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor. <br /> Type of Pump H.P. <br /> I a f <br /> PUMP REPLACEMENT; / State Work <br /> Done <br /> !� <br /> PUMP REPAIR-:— .— �,.., ..�.� -... ,. ,r:.o.l.,.•....r .�. . .... <br /> . /? State Work Done = �' <br /> ES•TRUCTION OF WELL: Well Diameter � <br /> E Approximate Depth <br /> v Describe Material and Procedure <br /> i <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 €urnish1the San Joaquin Local Health District a .: <br /> WELL DRILLERS REPORT of the well and notify them before puttingthe• 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 GROUTING AND A FINAL INSPECTION. �- <br /> SIGNED ft,7 77?. TITLE s <br /> DRAW PLOT PLAN ON REVERSE SIDE ' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE r. ;l <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IFI AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 7 <br /> E H 1426 Rev. 1-74 1-74 2M <br />