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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO&3FFICE USE: r 1601 E. Hazelton Ave. , Stockton, Calif. f} ` <br /> Telephone: (209) 466-6781 rj <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 6,y0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued9_ <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 thejSan Joaquin Local Health District'. <br /> JOB ADDRESS/LOCATION � ,it rvd <br /> l�C CENSUS TRACT <br /> Owner's Name Phone <br /> Address / �� � > City 2� /�� <br /> Contractor' me License #.:V_ t�0d('�hone 5 <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN /_7 RECONDITION / DESTRUCTION �T <br /> PUMP INSTALLATION/ / PUMP REPAIR/—/ PUMP REPLACIMENT <br /> 77 <br /> Other _F7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTBER <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 4� <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal In tailed By:- <br /> PUMP <br /> :PUMP INSTALLATION: Contractor gd` <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done .. <br /> PUMP .REPAIR: / / State Work Done <br /> ES•TRUCTION OF WELL: e 1 Diameter r 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 FIMAK VATS <br /> after completion of my work on a new well. I will furnish the San Joaquin Local Health District a <br /> WILL DRILLERS REPORT of the well and notify them before putting the well in use. The atinve <br /> information is true to the best of myknowledge and belief. I WILL CALL FOR A GROUT IeSPECTI <br /> PRIOR TO GR ING AND NAL INS ECTION. <br /> SIGNED TITLE .� <br /> W PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ..- <br /> ADDITIONAL CON MTS: <br /> PHASE II GROUT 5SPAZION PHASE FINAL INSPECTION <br /> INSPECTION BY INSPECTION DA E -? <br /> 3V76 24,E N 1426 Rev. 1-74 <br />