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to 6FICE <br /> SAN JOAQUIN LOCAL HEALTH DISTRICTFOFi USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> I. Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. T//- "/ <br /> 1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete in Triplicate) Zo(-- vso- C 7 <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 /> f County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> :TOB ADDRESS/LOCATION Y' / i-f e� l'� CENSUS TRACT <br /> Owner's Name ,�+�. ' �S Gt �j t� 1�°,�"&� _ _ Phone <br /> Address City - <br /> h J <br /> Contractor's Name License # /&,PA-� Phone <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN -/7 RECONDITION /7 DESTRUCTION %T <br /> y PUMP INSTALLATION / / PUMP REPAIR /77—PUMP REPLACEMENT f7 �I <br /> Other / I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY _ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/.SEEPAGE PIT OTHER f <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USETYPE 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 /> i T Irrigation Gravel Pack Depth of Grout Seal <br /> E Cathodic Protection " Rotary Type of Grout <br /> I Disposal Other Other Information <br /> Geophysical Surface Seal Installed B : <br /> PUMP INSTALLATION: Contractor <br /> -� -- Type of Pump H.P. _ <br /> PUMP REPLACEMENT: f-1 ' State Work Done <br /> PUMP '.REPAIR: I� State Work Doneeel <br /> , <br /> � t <br /> PES-TRUCTION OF WELL: Well. Diameter Approximate Depth <br /> Describe Material and Procedure <br /> Z 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- m y.knowledge nd°-belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO PIQUTING AND,/A FINAL IION. <br /> f SIGNED _ - TITLEi�" <br /> ( LOT 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 PHASE III FINAL INSPECT ON <br /> INSPECTION BY DATE INSPECTION B DATE L <br /> i E H 1426 Rev. 1--74 1-7,4 2M * -- <br />