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Y SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO ;'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. -7 - 6-7S70� <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7�-��/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date .Issued�/6-7.G <br /> . (Complete In Triplicate) <br /> Application is hereby made+ to the San Joaquin Local health District for a permit to construct <br /> sand/or install the work herein described. This application is made in compliance with Sen Joaquin' <br /> County Ordinance"No. 1862 and the Rules .and Regulations of the San Joaquin Local Health District. <br /> �% <br /> JOB ADDRESS/LOCATION r CENSUS TRACT <br /> a <br /> Owner 16 Name' , phone � 2�7 j <br /> Address, City <br /> l <br /> Contractor's Y � 5- <br /> Name ,. �1 P License, # hone <br /> TYPE OF WORK (Check) : NEW WELT/ EPEN 'x ;{RECONDITION /? DESTRUCTION f7 <br /> PUMP INSTALLATION / tFMP REPAIR'/� PUMP REPLACEMENT /7 <br /> Other - <br /> DISTANCE TO NEAREST: SEPTIC TANK ;_ SEWER LINES Tx.PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE I PRIVATE DOMESTIC WELt�-' ' PUBLIC DOMESTIC WELL -. <br /> INTENDED USE TYPE QF WELL CONSTRUCTION SPECIFICATIONS <br /> dustrial Cable Tool Dia. of Well Excavation <br /> �/ Domestic/private Drilled Dia. of_W.ell,4asirig �• _�1 <br />�- Domestic/public` ' }riven ' Gauge of Casing / � v <br /> Irrigation 1 Gravel 'Pack Depth of Grout Seal <br /> j Cathodic Protection Rotary. Type of Grout <br /> Disposal .-Other Other Information ' <br /> Geophysical it Sutface Seal Installed 'B <br /> PUMP INSTALLATION: Contractor-' } <br /> . Type of Fuuap ---- _.. R.P. <br /> PUNP REPLACEMENTc"'. ' /-7 State Work Done - « <br /> PUMP .REPAIR: / / State Work Done <br /> ; DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> VI 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 arid ,notify them before putting- the..well. in use.... ,The above <br /> information is trueto the-best of. nay..knowledge and belief. I WILL CALL FOR A GROUT INSPECTION„ <br /> PRIOR TO GROUTIN D A FINAL I ; ION <br /> ,, SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE. <br /> - - FOR DEPARTMENT USE `ONLY .: <br /> PHASE I <br /> I' APPLICATION' ACCEPTED BY ';� ,� _ _ --.._� s 4 ._ _ y - __.-:--DATE-" <br /> ." �� ` <br /> i <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIRM PHASE III FINAL INSPECTI <br /> (( INSPECTION BY DATE2 } INSPECTION BY DATE D <br /> E H 1426 RAv. 1-74 ! <br />