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f, SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Vis-1- 3Gtc' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1/ -/9' /Y- <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 Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �EN Y3' f � <br /> +" SU TRACT <br /> Owner's Name ol <br /> �'/ Cl, / / `4 ' �,% �` � �� <br /> _ -- -,^r-fi .� , Phone k,/y-cs��✓`/��`� H <br /> Address City <br /> Contracgor's Name c w P License # Phone <br /> ,La _ <br /> TYPE OF WORK (Check): NEW WELL/_7 DEEPEN /_7 RECONDITION /_7 DESTRUCTION /'7 <br /> PUMP INSTALLATION % PUMP REPAIR / / PUMP REPLACEMENT <br /> Other 0Ca Le <br /> �. <br /> P /L <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 <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 <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMPREPLACEMENT: j//- State Work Done <br /> PU1P.REPAIR: 7 State Work Done <br /> ,?ES TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all lawsand 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 my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED <br /> TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE I U - 9PECTI N PHAS AL INSPECTION <br /> INSPECTION BY -DATE INSPECTION BY DATE <br />' E H 1426 <br /> Rev. 1-74 <br /> �., <br /> 1-74 2M4 <br />