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�na <br /> V r <br /> SAN JOAQUINLOCAI,.HEALTH DISTRICT <br /> FOSrO FICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br />` Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ZZ- / <br /> THIS-PERMIT EXPIRES 1..11E R FROM DATE ISSUED Date Issued <br /> (Complete,-In Triplicate) .a.- - 'i <br /> Applicationis hereby made to the San Joaquin Local Health District for a,pexrmit 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 c .Sa'n�aur-, _ CENSUS TRACT <br /> Y <br /> Owner°s Name #< " v Phone <br /> r► <br /> 'Address 6"" ..— City G. <br /> Contractor s .Name License # 1212 - Phone -? <br /> TYPE-OF WORK (Check): - NEW WELL "FT DEEPEN,"!7 RECONDITION /� DESTRUCTION f7 <br /> PUMP INSTALLATION �j PUMP REPAIR j� PUMP REPLACEMENT <br /> Other j / <br /> ` DISTANCE TO .NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE -PIT OTHER <br /> PROPERTY LINE. - PRIVATE D0149ST:IC WELL PUBLIC"DOMESTIC WELL <br /> i 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 Surface Seal Installed B : <br /> i PUMPrINSTALLATION: Contractor. f .. . <br /> Type 'of Pump r2 � H.P. <br /> PUMP REPLACEMENT: State Work Donee 4Toe vn4 <br /> i PUMP :REPAIR: State Work Done r,Y <br /> C <br /> ES;TRUCTION 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_ utting-the..well in use.. The above <br /> information is true to the-best of my know edge an bel I WILL CALL FORA"GROUT INSPECTION <br /> PRIOR TO SE2ffjNG AND FINAL, INSPECT N. <br /> l SIGNED <br /> DRAW PLAN N REVER IDE <br /> F EPARTMENT USE ONLY <br /> PRASE I <br /> i APPLICATION ACCEPTED "BY DATE <br /> j ADDITIONAL.COMMENTS: , <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> r ,� E H' 1426 Rev. 1-74 I-74 2M <br />