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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 'FOE OFFICE USE: 160.1 E. Hazelton Ave.. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> 7Lc•c APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. "�'�•g' b <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. app lication is made, in compliance with .San Joaquiny <br /> County Ordinance No. 1.862 and the Rules and, Regulations. of the San Joaquin Local Health. District. <br /> JOB ADDRESS/LOCATION Q , L I-z- CENSUS TRACT <br /> Owner's Name Phone <br /> / y <br /> Address_ -__ City -SCA�p �n _ <br /> - 07 <br /> Contractor's Name .. --ap99 License # Phone <br /> i <br /> RTYPE OF WORK (CYreck) -�—NEW WELL / / DEEPEN / / RECONDITION /_/ DESTRUCTION �_ J_9 <br /> PUMP 4,I-NSTALLATION ./ / PUMP REPAIR / f PUMP REPLACEMENT <br /> Other <br /> [? <br /> DISTANCE TO NEAREST: ,SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD'n - CESSPOOL/SEEPAGE PIT _ OTHER / <br /> ` ,,,. _.. P_ROP.ERTY LINE,'-, PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL' <br /> INTENDED USE TYPE OF WELL. CONSTRUCTION SPECIFICATIONS ,, �' (b . <br /> Industrial . Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> g p <br /> Irrigation Gravel Pack Depth of Grout Seal,-- <br /> Cathodic <br /> _ <br /> Cathodic Protection Rotary Type of Grout ,- <br /> Disposal. Other Other Informa,tdo; <br /> Geophysical Surface Seat Installe-dr By: <br /> PUMP INSTALLATION; Contractor . <br /> Type of Pump H.P. ' <br /> PUMP REPLACEMENT: / / State Work Done - - - <br /> PUMP .REPAIR:: JV . State Work Done p, _ .'_ - < <br /> DES-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 the well 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 GROUTTNQ AND A FI IN PECTION. <br /> SIGNED TITLE _ ,( <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: ' <br /> PHASE II GROUT INSPECTION /; P S I/FI INSPECTION X <br /> INSPECTION BY DATE INSPECTION DATE 12 <br /> E H 1426 Rev. . 1-74 <br />