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SAN JOAQUIN LOCAL HEALTH DISTRICT v <br /> f_0S70FFICE 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 /!. ay-2e <br /> (Complete In Triplicate) <br /> Application is hereby made to tie 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 Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONf4/2.0 + f <br /> * - • <br /> ?�4SUS TRACT <br /> Owner's Nam' ti Phone 94 I " l <br /> Address Q U . Gam--- <br /> .. City - n <br /> Contractor's Name License ��2. % Phone <br /> i <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN <br /> /� f fRECONDITION ff DESTRUCTION <br /> PUMP INSTALLATION 'I_IPUMP <br /> I <br /> REPAIR / PUMP REPLACEMENT / . <br /> Other_/z 7.. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESPIT•'PRIVY <br /> 4y <br /> SEWAGE DISPOSAL FIELD I CESSPOOL/SEEPAGE PIT OTHER <br /> 4 <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL , 6 PUBLIC DOMESTIC WELL <br /> t INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> 3 Industrial,;., _- :_Cable=-Tool.----�- i'Dia. of Well Excavation <br /> 'Domestic/private 'Drilled <br /> Dia. of�Wel1 Casing <br /> -Domestic/public Driven Gaugedbf Casing <br /> Irrigation Gravel Pack Depth/of Grout Seal * a, <br /> Cathodic Protection Rotary Type�of Grout <br /> Disposal _ Other Other Information <br /> Geophysical. Surface Seal Installed B <br /> PUMP INSTALLATION: ' Contractor M <br /> Type ,of Pump 9 H.P. - 1 <br /> PUMP REPLACEMENT: '� <br /> / / State Work Dorie � <br /> PUMP :REPAIR: Nr r� <br /> State Work Done 4 <br /> DESTRUCTION OF WELL:. .. Well Diameter ! � � <br /> i Approximate Depth <br /> Describe Material and Procedure y <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 ''con,'truction. 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. mi knowledge and belief. I WILL CALL -FOR A GROUT INSPECTION <br /> PRIOR TO GROUTT AN A­kNSPEC ON, <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> - <br /> APPLICATION ACCEPTED BY L- DATE)) <br /> ADDITIONAL COMMENTS: <br /> PHASE II -GROUT INSPECTION PHAU II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ? ?� <br /> E H 1.426. . Rev.�1-74 <br />