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f -pep 4 <br /> SAN JOAQUIN LO AL HEALTH DISTRICT <br /> FOF: OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;��--#z9614,1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> rand/or install the work herein described. This application Is made in compliance wAXh San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations-of the San eJo uin Local Health District. <br /> JOB ADDRESS/LOCATION f3 /y _ 5 <br /> CENSUS TRACT S <br /> Owner's Name <br /> Phone <br /> Address City <br /> Contractor's Name License. .# � � Phone -- <br /> Zed <br /> TYPE OF WORK (Check) : NEW WELLDEEPEN '/-7 RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR '/-7 PUMP REPLACEMENT / f- r <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK jSEWER LINES PIT PRIVY ' <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL j <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation p <br /> �_ Domestic/private Drilled Dia. of Well Casing s <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal r <br /> Cathodic Protection _k:::� 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 /> PUMP .REPAIR: /7 State Work Done <br /> DES.TAUCTION 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 Distric <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 GIROUTING.AND A TIM INSPEjff ION. <br /> SIGNEDTITLE r -o <br /> DRAW PEZ PLAN ON REVERSE SIDE <br /> F DEP TMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED B DATE LL-76 <br /> ADDITIONAL COMMENTS: <br /> -WE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE a2 b <br /> _E H 1426 Rev. 1-74 ),/7q 9M <br />