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t � SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F08,OFFICE USE: �� 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. /75--/ <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 pf the San Joaqu Lo e It �trict. <br /> JOB ADDRESS/LOCATION _ CENSUS TRAC A"d <br /> A <br /> Owner's Nam>e` Phone <br /> Address �`7/ © D ��C/-' ��G�•� Div a� City l c cl-r- aIV- <br /> Contractor's Name License # p/ p Phone <br /> -�---- SY?-o3� <br /> TYPE OF WORK (Check): NEW WELL /-Zf—D EEPEN /7 RECONDITION /7 DESTRUCTION /-7 <br /> --� <br /> PUMP INSTALLATION /l PUMP REPAIR /—/ PUMP REPLACEMENT- 17 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK pz�c_SEWE LINES PiT PRIVY <br /> SEWAGE DISPOSAL FIELD/ Lou-P, CESSPOOL/SEEPAGE PIY/7r�— OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIO S <br /> Industrial Cable Tool Dia. of Well Excavation o <br /> stic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> �rigation Gravel Pack Depth of Grout al <br /> Cathodic Protection Mary Type of Grout <br /> Disposal Other Other Information �' a <br /> Geophysical SurfAce Seal Installed BY: <br /> PUMP INSTALLATION: Contractor /.L O <br /> Type of Pump A H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: /7 State Work Done <br /> ,SES-TRUCTION 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 thewell in use.. The above <br /> inform on is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO UTING AND- A F CT N. <br /> SIGNED TITLE d eQl lI f <br /> W PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYC DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY , DATE ----'_ -�— INSPECTION BY j�, DATE t` r <br />,l E H 1426 Rev, 1-74 - <br /> 1-74 Zf-" <br />