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�J61 SAN JOAQUIN LOCAL HEALTH DISTRICT +' <br /> FOR OFFICE 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 02 <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 Joaqu4 Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name License # 2?jQZ1d Phone 5IS//�i� <br /> TYPE OF WORK (Check) : NEW WELL /(�/� DEEPEN / / RECONDITION /_/ DESTRUCTION /_7 O(, <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 _j <br /> Other / / ,Y <br /> J <br /> DISTANCE TO NEAREST: SEPTIC TANK /Dnp SEWER LINES PIT PRIVY - 9 <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 164 %zj <br /> Irrigation Gravel Pack Depth of Grout Seal 5 <br /> Cathodic Protection /ji Rotary Type of Grout yz_2 <br /> Disposal Other Other Information V-1116 -h <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: /% State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe 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 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 FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A AL INSPECTION. <br /> SIGNED TITLEfp�AIJ PLOT PLAN ON VERSE SIDE) <br /> FOR DEPART44ENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE^' ---� <br /> ADDITIONAL COMMENTS: <br /> PHASE I ROUT INSPECTION PHAS I_LI/,FWAL INSPECT ON <br /> INSPECTION BY DATE ��,��/7f� INSPECTI N BY ,DATE ,�7 <br /> 0,/77 2M <br /> E H 1426 Rev. - 1-74 <br /> _ <br />