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�L SAN JOAQUIN LOCAL HEALTH DISTRICT - - <br /> FOFirOFFICE USE. 1601 E. Hazelton`Ave. , Stockton, Calif. <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/2,- <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin -Local Health District icor 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. 1862and the Rules and- Regula ions of the San Joaquin Local HealthDistrict. <br /> JOB ADDRESS/LOCATI� �tY� I/� CENSUS TRACT d4vvc <br /> Owner's Name Phone <br /> Address - City . I <br /> Contractor's Name <br /> License-# 29&X-) Phone <br /> I <br /> TYPE -OF WORK (Check): NEW WELL -/? DEEPEN /7 RECONDITION /7 DESTRUCTION / <br /> -PUMP INSTALLATION / J PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <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 O <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 l` <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information; <br /> Geophysical Surface Seal Installed- By: <br /> _ 9r <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.F. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUHP .RE_P-AIR: /_7 State Work Done <br /> ES;TRUCTION OF WELL: Well Diameter Approximate Depth 10 (,) <br /> Describe Material and Procedure 1 L L W f'T 04 <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.R The-above ,�y <br /> information is true to the-best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GgRMEG AND A FINAL I PECTION. <br /> SIGNER y2kn, TITLEGO <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ` <br /> APPLICATION ACCEPTEDBY DATE <br /> ADDITIONAL COMMENTS: I° <br /> PHASE II GROUT INSPECtION PHA I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY j ATE <br /> E H 1426 Rev. 1-74 CAe ,,h ' ,-7A Ou <br />