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SAN JOAQUIN L[ICAL HEALTH DISTRICT <br /> F0 :OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE 'ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to- the Son 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 /> JOB ADDRESS/LOCATION jarCENSUS TRACT <br /> f Owner's Name Phone , G <br /> Address <br /> City <br /> Contractor's Name + License # � Phone <br /> TYPE OF WORK (Check) : NEW WELL '.1 DEEPEN '/''__RECONDITION — DESTRUCTION /_ <br /> PUMP INSTALLATION j /�, 'PUMP REPAIR '/� PUMP REPLACEMENT I=T <br /> DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINES PIT PRIVY N <br /> SEWAGE-DISPOSAL FIELD 66# -CESSPOOL/SEEPAGE PIT OTHER {t1 <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 /> r Domestic/private Drilled . I —Di.a. of Well Casing <br /> Domestic/public Driven -. Gauge of Casing �c <br /> Irrigation : Gravel Pack --;-Depth of Grout Seal <br /> Cathodic Protection ' .-- Rotary ' �. , . Type of Grout <br /> Disposal Other. .- Other- Information <br /> Geophysical .v� : : -��` ~ = Surface :Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump t H.P. <br /> t PUMP REPLACEMENT: / / State Work Done <br /> 'PUMP .REPAIR: _/ /_.,;State_Work _Done, <br /> DESTRUCTION OF WELL: Well Diameter A' Approximate Depth <br /> Describe Material and Procedure � dozf <br /> I hereby agree to complywjith all la-Js 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 kn©wledge„_and b <br /> _. el;.ef. I WILL CALL -FOR,A GROUT INSPECTIO <br /> PRIOR TO GROUTING AND A VINAL INSPECTION. <br /> SIGNED ? ;TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE 'ONLY <br /> ` PHASE I r - <br /> APPLICATION ACCEPTED �SY DATE f 0�/ Z, <br /> . ADDITIONAL COMMENTS: <br /> P II f.AOUT I PECTION7 PH&n TAT/WAL INSPECTION <br /> INSPECTION AY DATE L INSPEr ION By/_ DATE <br /> —” <br /> 2M <br /> E H�1426 Rear. 1-74 r' _. <br />