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el SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOAOFFICE USE: 1601 E. Hazelton. Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 j <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Per, It No. - -4 3 p <br /> i <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date' <br /> Issued 1n- -2-!-_7 <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 Joaquinl <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. ' <br /> II <br /> JOB ADDRESS/LOCATION / CENSUS -TRACT <br /> 0 <br /> Owner's Name Phone i, <br /> j <br /> Address DC7 City,_ <br /> Contractor's Name � .� /� Phone-?(,J- <br /> License j <br /> f,c.: ljl <br /> TYPE OF WORM (Check): NEW WELL/?'DEEPEN /7 RECONDITION /_7 DESTRUCTION <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 PITOTHER <br /> " PROPERTY LINE -- PRIVATE DOMESTIC WELL' PUBLIC DOMESTI1 WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS q <br /> Industrial Cable Tool Dia. of Well Excavation it <br /> Domestic/private Drilled Dia. of Well Casing a <br /> Domestic/public Driven Gauge of Casing �I <br /> Irrigation Gravel Pack Depth of Grout Seal iG <br /> Cathodic Protection Rotary ' Type of Grout <br /> Disposal Other Other Information iG <br /> Geophysical Surface Seal Installed By,, -- if " .. <br /> PUMP INSTALLATION: ContractorType of Pump ?..c.�.�- ._ ....,.,..._�_. !IE H.P. <br /> i <br /> PUMP REPLACEMENT: / / State Work Done " <br /> .PLW REPAIR: State Work Done �.c.G / <br /> •,?ES•TRUCTION OF WELL: Well Diametert Approximate] Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Locall 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 Locall'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 GRO N AND,A FI AL INSPECTION. ...--•- <br /> SIGNED TITLE <br /> s ? RAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> E I `-` -- ..._ <br /> APPLICATION ACCEPTED <br /> PHASBY DATE <br /> ADDITIQNAL COMMENTS: <br /> PHASE II GROUT INSPECTION _ - - - �T PHASE IIIIFINAL-INSPECTION ./ <br /> INSPECTION BY DATE INSPECTION BY DATE ��2-�7-7 7 <br /> `t E H 1426 Rev. 1-74 <br /> 1-74 2M / <br />