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SAN JOAQUIN LOCAL-.HEALTH DISTRICT <br /> FOR <br /> O ICE USE: 1601 E. Hazelton Ave. , 'Stockton; Calif. ' <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -7f-,W <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued ��y <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 /> ou ty Ordinance No. 1$62 a} d the Rules and :Regul ions of the Sari J aquin Local Health District. <br /> � <br /> TOB ADDRESS/LOCATION,r 3�! —Sao'Oo'o CENSUS TRACT <br /> Owner's Name <br /> �- - Phone <br /> Address rid ,�� 9G �rG--v�� � Cit M <br /> Y � cert C_ct <br />," Contractor's Name 4 License # <br /> If 42,36-,Phone ?� <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN '/�4/ RECONDITION / / DESTRUCTION /_ <br /> PUMP INSTALLATION / J PUMP REPAIR /k'/ PUMP REPLACEMENT <br /> Other <br /> DISTANCE TQ NEAREST: SEPTIC TANK SEWER LINES PTT 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 <br /> Industrial Cable Tool Dia, of Well Excavation t` <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 Il <br /> I <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump -r r H.P. <br /> PUMP REPLACEMENT: "'/ / State Work -Done I <br /> Y <br /> PUMP .R9PAIR: �. <br /> State Work Done 30 a <br /> DESTRUCTION OF WELL Well Diameter e , <br /> Describe Material and Procedure Approximate Depth <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 FORA GROUT INSPECTION <br /> PRIOR TO GROU ING AND A FINAL INSP ON <br /> SIGNED' . <br /> •`" TILE . <br /> ( W PL T PLAN ON R ' RSE SIDE) <br /> PHASE T �"- <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION -­-PHAS III/FINALeINSPECTION <br /> INSPECTION BY DATE INSPECTION <br /> INSPECTION AV iDATE <br /> E H 1426 Rev- 1-74 ci�77 2M <br /> � - <br />