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CJy SAN JOAQUIN LOCAL HEALTH DISTRICT ru <br /> FOR: OFFICE USE; 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 7 . Telephone: . (209) 466-6781 <br /> A e"11 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Berndt No. 7,�- �. <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 fora permit to construct <br /> and/or install the work herein described. This application is made in compliance with Sar: Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. . <br /> JOB ADDRESS/LOCATION /fI`.,J ,� CENSUS TRACT <br /> Owner's Name Phone l 0 2 <br /> Address 2, 2 City ' <br /> Contractor's Name Licensed Phone - <br /> TYPE OF -WORK (Check): NEW WELL -/7 DEEPENJ7/? RECONDITION '/-7 "DESTRUCTION f7­ 74 <br /> iE <br /> PUMP INSTALLATION / / PUMP REPAIR'/? PUMP REPLACEMENT <br /> Other Ll <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 Weld Casing \ <br /> 4 Domestic/publict .Driven - _Gauge of_ Cas.ing�� <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection_ Rotary � Jype_of Grout <br /> '` Disposal Other Other Information <br /> ---.Geophysical � t - Surface Seamminstalled 'By <br /> PUMP INSTALLATION: Contractor hJ <br /> Type of Pump <br /> f ' <br /> PUMP REPLACEMENT: State Worlr DonePw ` <br /> PUMP ,REPAIR: / / State Work.'.Done <br /> DE&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 <br /> istrict -.and the State of California pertaining;.to or regulating well 'construction. Within FIFTEEN DAYS <br /> after completion of my work on a new dell, I will furnish the San Joaquin Local Health District a <br /> e 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 FORA GROUT INSPECTION <br /> PRIOR TO GROUTING D A F INSPE ION. <br /> SIGNED TITLE <br /> RAW PLOT PLAN ON REVERSE SIDE r' <br /> { FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPT.ICATION ACCEPTED BY AJQ.. w DATE <br /> ADDITIONAL COMMENTS: , <br /> ,PHASE II GROUT INSPECTION PHA I NAL INSPECTION <br /> INSPECTION BY DATE -5-BY DATE ^ <br /> E H 1426• Rev. 1-74 r - h/75 2M = jj <br />