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SAN JOAQUIN LOCAL 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. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued 6-.3a-2 <br /> (Complete In Triplicate) <br /> Application is hereby made� to the San Joaquin Local Health District fora permit to construct <br /> and/or install the work herein described. This application is-made in compliance with San 'Joaqui <br /> County Ordinance No. 1862 and the Rulej and <br /> Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOC CENSUS TRACT - <br /> Owner's Name Phone <br /> Address L22 <br /> 2 Ci <br /> Contractor's Name License : 4hone4gg76 <br /> y- ice•'_._-+._ ..-z- _ <br /> TYPE OF WORK (Check): NEW WELL /? DEEPEN '/? f RECONDITION I DESTRUCTION J j <br /> PUMP INSTALLATION J / PUMP REPAIR ) PUMP REPLACEMENT <br /> Other j/7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> j' SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <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 /> ..�_ 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. '- <br /> _ Surface Seal IIISta11ed '$y: <br /> PUMP INSTALLATION: Contractor - <br /> r <br /> Type .of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> t-PUL"R'.REPAIR-:-- ,. -StaterWork Do <br /> DES'TItUCTION OF WELL:. Well -Diameter A roximate <br /> Depth \ <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health Distri <br /> and the State of California q ct <br /> f pertaining to or regulating well''construction. Within FIFTEEN DAYS <br /> after completion of my work on anew 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 INSPECTION <br /> ' PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE Xh <br /> ` (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE. I FOR DEPARTMENT USE ONLY <br /> APPLICATION' ACCEPTED BY DATE ' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT. i SPECTIoN PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY <f f7 • : DATE <br /> - - <br /> 4 E H 1426 Rev. 1-74 r''' .. 1,17K. 12M <br />