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Cp r SAN JOAQUIN LOCAL BEALTH DISTRICT _ -"FOR USE <br /> CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) ,.466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 5� <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 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 /> ;YOB ADDRESS/LOCATION OO � ea� �.,� <br /> CENSUS TRACT <br /> Owner's Name ,� r .� Phone <br /> Address _ 9 0?6.....9 city <br /> Contractor's Name License. # � � y Phone ;�- <br /> TYPE OF WORK (Check): NEW WELL i7 DEEPENT7/_7 RECONDITION /7 DESTRUCTION /7 <br /> ' PUMP INSTALLATION /X/ PUMP REPAIR <br /> Other REPLACEMENT /7 <br /> / / �-' <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 rO <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 Pry Type f Grout <br /> otection Rotary t <br /> o. <br /> Disposal , . - Other Other Information <br /> Geophysical. Surface Seal Installed- By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT. El- State Work Done <br /> PUMP :REPAIR: /)-(7—State-Work-Done-!Q <br /> ES-TRUCTION OF WELL: Well Diameterpproximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San .Joaquin Local Health District t <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--knowled a d--b lief. I WILL CALL FOR A GROUT INSPECTION f <br /> PRIOR TO UTING AND A FINAL INSPE zON. 3 <br /> SIGNED TLE <br /> (DRA PLAN ON RE SE SIDE <br /> F DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BV <br /> DATE -/ S <br /> ADDITIONAL COMMENTS: ; <br /> PHASE ROUT INSPECTION P114SR IULFINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE --E,A 5- � <br /> 1426 Rev. 1-74 1-74 2M <br />