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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F014 OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. �l�-� � r <br /> Teleptiorie : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -- <br /> -WO <br /> r 3 (Y <br /> `THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Appltation- s ereby 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. 1.862 and the Rules and Regulation of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION pf G� /V � N <br /> �fil P16 <br /> c 7L 'ENSUS TRACT <br /> Owner's Name T Phone 1-3 IFZ <br /> Address j ���• a+► <br /> City <br /> Contractor's Name ®� I�f�L� �fG License <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN /_% RECONDITION /_/ DESTRUCTION /_7 _ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT f f V <br /> Other / / — O, <br /> DISTANCE TO :AREST: SEPTIC-'TANK--- LINES-- <br /> SEWAGE <br /> INES-SEWAGE DISPOSAL,�j FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ROPERTY -LINE Gr PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SP4CIFICATIONS <br /> Industrial Cable Tool Dia. of Well. Excavation! /,9�`�i•��j <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing _! <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 /> PUMP REPAIR: / / State Work Done "' <br /> Q3 <br /> DES-TRUCTION 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 District <br /> �+ <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 Distract A <br /> WELL DRILLERS REPORT of `the well �and notif them before <br /> y 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 OUTING D A FI INSPECTION. <br /> SIGNED 1 <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -7DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE T I/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> Y/7 <br /> E H 1426 Rev- 1-74 b/77 - 2M <br />