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C� 1� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> # FOF3rOFFICE USE; 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 $� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �S r CtJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 2 J l- 26— <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 Joaquit <br /> County Ordinance No. 1852 nd the Rules and <br /> Reg ulat ons of the San Joaquin Local Health District. <br /> 'JOB ADDRESS/LOCATION CENSUS TRACT <br /> j t, <br /> Owner.'s Name Phone <br /> �J U� <br /> Address ' p� . .,C City <br /> I <br /> Contractor's Name A License &U��, Phone <br /> 7 <br /> f ' <br /> " TYPE OF WORK (Check): NEW WELL / DEEPEN ,/7 RECONDITION /7 DESTRUCTION L7 <br /> AL <br /> PUMP INSTLATION PUI� REPAIR /7 PUMP REPLACEMENT �f <br /> Other <br /> DISTANCE TO NEAREST: "SEPTIC TANK a SEWER LINES PIT PRIVY <br /> } E SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> 1 PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 1' Cable Tool Dia. of Well Excavation <br /> Domestic/private` Drilled Dia. of Well Casing <br /> Domestic/public - Driven Gauge of Casing 1 (�► <br /> Irrigation gravel Pack Depth of Grout Seal d <br /> Cathodic Protection ✓Rotary Type of Grout <br /> Disposal ' r E Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: ''Contractor <br /> A Type of Pump H.P. <br /> ;y E <br /> PUMP REPLACEMENT: j// State Work Done <br /> . PUMP '.REPAIR: L7 State Work Done <br /> F <br /> ESIRUCTION OF WELL: � Well Diameter Approximate Depth <br /> j .. 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. 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 MPECTION. <br /> SIGNED / ' TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ? S <br /> ADDITIONAL COMMENTS: /,sem, re — o �f of � le� � Cn ` <br /> PHASE II GROUT INSPECTION PRASE I ,FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYO& DATE <br /> l <br /> - 3 E H 1426 Rev. 1-74 1-74 2M <br /> ? '. <br />