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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> f FOFx;OFFICE USE 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466"-6781 <br /> Permit No. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> R � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> Com <br /> ( 1 Pete In Triplicate) <br /> f 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 he San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �¢�D <br /> Ve*o , CENSUS TRACT ! <br /> Owner's Name <br /> Phone .51',4/( <br /> i Address T �' <br /> . City F� <br /> Contractor's Name { <br /> License _ 'Phone'? <br /> TYPE OF WORK (Check): NEW WELL / EEP_EN_/7 RLCONDIT O%N/ .tA DESTRUCTION,-/--7.. _ - I <br /> PUMP INSTALLATION / / /PUMP REPAIR' PUMP REPLACEMENT- <br /> 1-7 <br /> Other ./ 7 <br /> DIS• �CE' OL DEAREST: "SEPTIC TANK t <br /> 7 SEWER LINES PIT PRIVY <br /> 8EWAGE <br /> �' DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER � <br /> PROPERTY...LINE -- PRIVATE DOMESTIC WELL" t PUBLIC DOMESTIC WELL <br /> INTENDED USE -.TYPE"OF WELL GOPISTRUCTI)N SPECIFICATIONS <br /> Industrial : -- . Cable Tool Dia. of Wall Excavation . fi <br /> l Domestic/private Drilled —Dia._ of_We11 Casing <br /> Domestic/public t . -_ - Driven_ _ <br />' <br /> Irrigation �,._, � Gauge of Casing <br /> S Gravel Pack Depth of Grout< Seal ' <br /> Cathodic Protection Rotary L ` Type of Grout"'' <br /> —Disposal z S f <br /> Other Other In w- <br />!, <br /> _Geophysical. wt Surface <br /> TSeal Installed B <br /> PUMP INSTALLATION: Contractor <br /> E ,^ <br /> .M, <br /> fTYpe of_Pump A:P. <br /> _L,,C <br /> E <br /> PUMP REPLACEMENT: /t/ State Work Done <br /> P 7 State Work Done �`� <br /> UMP '.REPAIR: <br /> DESTRUCTION OF WELL: Well Diameter r <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply with-all laws--and-regur t1-on8'of the-San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> atter completion of mylUork 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 'GROUT INSPECTION <br /> PRIOR TO GROUTING D A= AL <br /> SIGNED <br /> TITLE ; <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPI,TCATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE/ <br /> PHASE II GROUT INSPECT N PHASE III FINAL DATEINSPECT ' <br /> INSPECTION BY _ <br /> - _ - .INSPECTION BY DATE ION <br /> E H .1426 r-/9'7,P-� ` <br /> Rev_. 1-74 µ <br />