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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1/ 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � a S' ts1 <br /> 7S10 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,r- <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 andd ulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION `� /� CENSUS TRACT <br /> Owner's Name 1 Phone <br /> Address Ce, City /0 <br /> Contractor's Name -1-4-1 License # D 16Phone ,� <br /> TYPE OF WORK (Check): NEW WELL/ DEEPEN/-7 RECONDITION /? DESTRUCTION /-J <br /> /ZPU1� <br /> PUMP INSTALLATION " REPAIR /7—pump REPLACEMENT /7 <br /> Other / 7 <br /> DISTANCE TO NEAREST: SEPTIC TANK/.,c�) SEWER L}NES 0n,.< PIT PRIVY _ <br /> SEWAGE DIS SAL FIELD/0ESSPOOL/SE PAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL/PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> In trial Cable Tool Dia. of Well Excavation W <br /> omestic/private Drilled Dia. of Well Casing (,f, /J% (n <br /> Domestic/public Driven Gauge of Casing ._- <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection otary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surfa Seal Installed BY: a <br /> PUMP INSTALLATION: Contractor 1 <br /> Type of Pu C� H. <br /> s <br /> PUMP REPLACEMENT: %/ State Work Done <br /> PUMP :REPAIR: /-7 State Work Done <br /> ,RES TRUCTION OF WELL: Wdll 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 /> information is true to the best of mv knowledge and belief. I WILL CALL FOR A GROUT INSPECTION' <br /> PRIOR ROUTING AND A F N. <br /> SIGNEDTITLES _7 <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHAS / <br /> APPLICATION ACCEPTED B ""r—jDATE ��— <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION �. PHASE I FINAL NSPECTION <br /> INSPECTION BY61/j&6,23 � l� DATE - T-7 S INSPECTION BY- " ATE '7_�- 75 <br /> 1 <br /> f E H 1426 Rev. 1-74 1-74 2M <br />