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'f SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> --f—OK—OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Per <br /> No. <br /> I <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6�- <br /> i <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 /> t - <br /> JOB ADDRESS/LOCATION Q _daiU <br /> r CENSUS TRACT <br /> Owner's Name Phone 241,aii� _ <br /> Address (� 3 City <br /> Contractor's Name � License 0WPhonfX71 <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN, /—/ RECONDITION_/ / DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES rj PIT PRIVY ' <br /> SEWAGE DISPO AL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE 4CP RIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL V' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _ Cable Tool Dia. of Well Excavation <br /> Domestic/private �__yDrilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel. Pack Depth of Grout Seal <br /> Cathodic Protection V 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 /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / 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 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 and notify them before putting thewell 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 /> f <br /> SIGNED V t7 Id- TITLE <br /> L2 CL14- (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II WUT INSPECTION PHASE II NAL INSPECTIO <br /> INSPECTION BY DATE - 3 ` INSPECTION BY DATE <br /> /77 _ 2M <br /> E H 1426 Rev- . 1-74 <br />