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r <br /> 9 'f SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFx.,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � �`�� �/i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -7S <br /> (Complete In Triplicate) <br /> Application- is hereby made to the Saiz 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. 4 <br /> .TOB ADDRESS/LOCATION � � ��a-�U� �1' CENSUS TRACT <br /> of o (4 -b <br /> Owner's Name t G- Q L7 Phone G z <br /> 65�t 3 _ f <br /> Address City ale <br /> Contractor's Name License U Phone <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN -/7 RECONDITION /—f DESTRUCTION` ,4 <br /> PUMP INSTALLATION J / PUMP REPAIR /_7 PUMP REPLACEMENT - 17 <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 N; <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 Surface Seal Installed 'B : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> \ f <br /> PUMP REPLACEMENT: , / / State Work Done <br /> PW REPAIR: /7 State Work Done <br /> 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 "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 tr to 'the-best.of my knowledge and belief. I WILL CALL FOR A ,GROUT INSPECTION <br /> PRIOR TO GRQUYI D A FINAL INSPECTION. ; <br /> SIGNED TITLEu <br /> DRAW PLOT PLAN ON REVERSE SIDE ' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE IIf <br /> APPLICATION ACCEPTED BY Y�.r{f DATES- � '� / <br /> ' <br /> ADDITIONAL COMMENTS: 0 . j <br /> PHASE II GROUT INSPECTIONPRASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E E H-.. u+ rr <br /> 1426 Rev. 1--74 - )I/?q 2N[ <br />