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I '1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS?OFFICE USE: G1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THUS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3-/} - 7r <br /> •1� - (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 Re ulatio s of the San Joaquin Local Health DiWict. <br /> r <br /> JOB ADDRESS/ CATION vj� CENSUS TRACT <br /> F � r <br /> Owner c s Na '�� Z_�_z4& Phone <br /> Address Q Cit <br /> Contractor's Name ,License �F� -' one4f-i� <br /> t�� .....�. .-�-_--� <•�•��..,.- *gip w -� .d.. � - .- <br /> TYPE OF WORK (Check): NEW WELL /-7 DEEPEN../_7 RECONDITION,/_7 DESTRUCTION /? M1 <br /> PUMPINSTALLATION J_7PUMP REPAIR /-7., PUMP REPLACEMENTLA <br /> j' Other /% 4 <br /> S I� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - 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 Drilled Dia. of Well Casing <br /> Domestic/public i Driven Gauge of Casing zj <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 By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> u + 'REPAIR: /? State Work Done- - <br /> iw3ESS;TRUCTION OF WELL: WellDiameter 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 Californiallpertaining to or regulating well 'construction. Within FIFTEEN DAYS <br /> after completion of my work0on 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.the .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. F <br /> SIGNED 1M TITLE -Vm <br /> (DRAW PLOT PLAN ON REVERSE SID — <br /> • . .•.•--- '�M °--•.,.,,.. FOR DEP T USE-ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �� 2 <br /> CC S• DATE <br /> ADDITIONAL COMMENTS: �I <br /> PHASE II GROUT1IINSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY IDATE INSPECTION BY. DATE <br /> t E H 1426 Rev. 1-74 1-74 2M <br />