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V <br /> SAN JOAQUIN WCAL-`IfEALTH DISTRICT <br /> 0T.*OFFICE USE: I/ 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 <br /> (o(qQ S. �sc+E-co,J A,e ,gyp. (Complete In Triplicate) ,?7 - 1/0-2_3 <br /> Application is hereby made to the San Joaquin Local Health District or 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 Ru es and Regulations of the San Joaquin Local Health District. <br /> J�DRESS/LOCATION C00' CENSUS TRACT <br /> Owner's Name Phone <br /> Address 7 City ' <br /> Contractor's Name License # Phone SiViet <br /> TYPE OF WORK (Check): NEW WELL � DEEPEN/7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR '/-7—pump REPLACEMENT /7 <br /> Other E7 <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 h <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial y - Cable Tool Dia-;-- of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing �► <br /> Domestic/public Driven Gauge of Casing <br /> --A Irrigation � Gravel Pack Depth- of Grout Seal. <br /> Cathodic Protection = Rotary Type-of Grout C <br /> Disposal 0 h Other Information ' ' <br /> Geophysical. Surface Seal Installed ,By <br /> PUMP INSTALLATION: Contractor C <br /> Type of Pu ` <br /> YP � A.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 refg*latUns of the an Joaquin Local Health District <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 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 INS P CTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PRASE III FINAL INSPECTION <br />' INSPECTION BY DATE INSPECTION BY 42Z - DATE - - <br /> E E H 1426 Rev. 1-74 ;` 4/75 2M <br />