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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0E- 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 1 YEAR FROM DATE ISSUED Date Issued f(�� <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 Regul tions of the San Joaquin Local Health District. <br /> 1 �a of <br /> JOB ADDRESS/LOCATION Sj ,� - . CENSUS TRACT <br /> Owner f s Name. - Q Phone " <br /> Address6/? City l <br /> / 4 <br /> Contractor's Name �—(� �/ / License p 'hone <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN /_/ RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTAL ATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK O SEWER LINEScS0 PIT PRIVY <br /> P SEWAGE DISPOSArLn FIELD QQ CESSPOOL/SEEPAGE PITO OTHER <br /> PROPERTY LINE AO PRIVATE DOMESTIC WEL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation rj <br /> Domestic/private Drilled Dia. of Well Casing p, <br /> Domestic/public Driven Gauge of Casing f <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 B <br /> y: All- <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 51strictl4� <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS `L? <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District <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 INSPECTIO <br /> PRIOR TO GROUTI14G IN INS CTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) �^ <br /> PHASE I FOR DEPARTMENT USE ONLY�� "{-t�.'-".�� f <br /> APPPP ON ACCEPTED�BY DATE fi <br /> h:2 <br /> ADDITIO AL COMMENTS: <br /> I - P SE II RUT I.N ECTION PHASE III/ I AL INSPECTION <br /> INSPECTION HY' _ DATE. � � INSP 'CYTON BY DATE <br /> ��.,Gf r ,P /7a / `� D �/✓G T� D , /96Z per to <br /> ' � 4 j1� fru ��--- re a .�`�i 6/77 2M <br /> E H °1426 Rev. � 1-74 . t <br />