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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i <br /> FORtOFFICE USE: 1601 E. Hazelton Ave. , -Stockton, Calif. <br /> t <br /> Telephone: --'-,1(2d9) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM-DATE ISSUED Date issued <br /> (Complete in Triplicate) <br /> Application is hexeby made to the Safi Joaquin Local Realth. 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. 1662 and the Rules and Regulations of the San Joaquin Local Health District. <br /> C JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner v s Name LL a Phone <br /> Address ,,-. Y City <br /> Contractor's Name License #aAVID Phone <br /> f f i <br /> TYPE OF WORK (Check): NEW WELL DEEPEN =/-77 RECONDITION /7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR REPLACEMENT %f <br /> Other /J ~— <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ', PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> "a='PROPERTYkLIKE,= 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 Diftled Dia: of Well Casing <br /> Domestic/public _ � :Driven ----!-Gauge of Casing <br /> Irri ation ` <br /> E E � _ Gravel Pack Depth of Grout Seal <br /> 4 Cathodic Protection- =~"' Rot6ky Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> ' PUMP INSTALLATION: ., } Contractor <br /> Type of Pump H.P. <br /> _ r <br /> PUMP REPLACEMENT:REPLACEMENT: / / 'St9te Work Done <br /> PUMP :REPAIR: <br /> State Work Doxie <br /> ESIRUCTION OF WELL: Well Diameter Approximate Depth <br /> 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 anew,w611, -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 & GROUT INSPECTION <br /> PRIOR TO GRO IN AND F AL INSPECTION, <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYX9 Z9�� DATE 3 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/ ,INAL INSPECTION <br /> INSPECTION BYDATE INSPECTION BY LZO, DATE <br /> E H 1426 Rev. 1-74 1--74 2M <br />