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- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FW,.OFFI,E USE:' f 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. T- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In 'triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit Co 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 �moi. . ;2:�,( Seca A CENSUS TRACT <br /> fOwner r s Name Phone <br /> Address Z`4-.5r j6 R Al- elCity s/,-, <br /> Contractor's Name License # /1321.1, -T <br /> ane <br /> TYPE OF WORK (Check) : NEW WELL '/4 DEEPEN '/-7 RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTLATION /�,/ PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> AL <br /> ' Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY e Y <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 <br /> Domestic/public Driven Gauge of Casing kr <br /> IrrigationGravel Pack Depth of Grout Seal <br /> Cathodic Protection� Rotary Type of Grouti� <br /> { Disposal Other Other Information <br /> i Geophysical �, Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor C oS <br /> Type of Pump H.P. / U <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP - State Work,-Done- L.f - <br /> �. <br /> ' ,RES-T _WELL: Well Diameter Approximate Depth <br /> Q.RUCTION OFDescribe 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 weA, 'I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before puttingthe- well in use.. The above <br /> information is true to the-best of. my knowled and elief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TOpi!aUTINGAND A FINAL INSP 0 <br /> SIGNED ��ITLE 1' <br /> PLO PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> � PHASE I �� <br /> APPLICATION ACCEPTED BY DATE , /� S� <br /> ADDITIONAL COMMENTS.: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION- BY 462LI DATE G1-/U--7S" <br /> E H 1426 Rev. 1-74 1774 2M -- <br />