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p� SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOL OFFICE USE: Vit/" 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 27 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. z' j <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 /> 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/LOCATION -,! - �� r�� CENSUS TRACT <br /> Owner's Name 1 �� Phone " 22O S <br /> Address �X3vr� �•Q ..,, .,.,,.,. __. City X-sC1& <br /> Contractor's NameLicense # Phone 9W-c� <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/-7 DEEPEN / / RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP' REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES. PIT PRIVY <br /> 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 r„ <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 �2 c��T 2 � � �[ C , <br /> PUMP .REPAIR: / / State Work Done + T <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 District <br /> and the State of California pertaining to or regulating well'cons-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 my knowledge and belief. I. WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING �gD ,A44EINAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW PI: T PLAN 'ON REVERSE SIDE 1' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSnCTION PASIIOINAL INSPECTI 1 <br /> INSPECTION BY DATE INSPECTION DATE "'' <br /> E H 1426 Rev. 1-74 <br /> 3/76 2M <br />