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CO <br /> r SAN JOAQUIN LOCAL HEALTH DISTRICT U �"d 1 9 <br /> FO11;OFrICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 616 k. <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 0` Toe <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 �� }n �, kC4CENSUS TRACT <br /> Owner's Name 4LPhone <br /> I <br /> Address ' : city1 �� <br /> Contractor's NameLicense. rPhone. 0-1 <br /> X1._- <br /> ,Jf• � �� <br /> TYPE OF WORK (Check4 EW LL / / DEEPEN / / RECONDITION / / DESTRUCTION-1-7 <br /> PUMP_'bINSTALLATION PUMP REPAIR/ / PUMP-REPLACEMENT /_7 ! <br /> D STANCE ,TO NEAREST: SEPTIC TANK ' SEWER LI-NESPTT PRIVY � <br /> SEWAGE�DIS POSAL -YIELD---'- CESSPOOL/SEEPAGE PIT OTHER ! <br /> PROP ERTY-E;INEF-PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL W <br /> INTENDED USE- w. _-TYPE~OF WELL ''' CONSTRUCTION SPECIFICATIONS <br /> rt �1 <br /> Industrial. ��� Cable` Tool � Dia. of Well Excavation <br /> T <br /> Domestic/private _gilled Dia, of Well Casing g'• <br /> Domes tie/public . � Driven Gauge of Casing <br /> jr-rigation "' Gravel Pack Depth of Grout Seal <br /> Cath c-Protection Rotary Type of Grout <br /> Disposal Other,_ �,..w- " "" Other Information <br /> Geophysical _Su-rf-ac`e-•Seal ,Installed -By: <br />..,.�z._. - <br /> PUMP INSTALLATION: Contractor <br /> " Type of Pump C,� , � i, ..----.._......_,._....._� H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP °REPAIR: / State Work Done f� <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 true to the best of. my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> e 'FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYE DATE f <br /> ADDITIONAL COMMENTS: P.M, <br /> PHASE II GROUT INSPECTION PHASE II /FINAL INS ECTION, ' /7x <br /> INSPECTION BY .,, . DATE r. INSPECTION BY DATE,. . <br /> } � S o 2g' ' 1177 _ 2M <br /> .,. E,.�I®1426 Rev. --l-74 • <br />