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SAN JOAQUIN LOCAL ;HEALTH DISTRICT <br /> FOR?OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7rt_ <br /> THIS PERMIT EXPIRES l YEAR 'FROM DATE ISSUED Date Issued <br /> �t :1, L (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health DistrAct 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 /> 1 'JOB ADDRESS/LOCATION f s�,/,�� �,,, <br /> L o ; CENSUS TRACT <br /> d <br /> Owner's Name O& Phone <br /> Address . ._� _ v city �fz <br /> Contractor's Name T, 0, License #,2AUlD Phone <br /> TYPE OF WORK (Check): NEW WELL/? DEEPEN J7 RECONDITION /� DESTRUCTION /-7 <br /> PUHP- INNSST-ALLATION / / PUMP REPAIR /-7—pump REPLAC T . . <br /> Other. 2�J z ! itJ . <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 r 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 _Othez. Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> F <br /> -_Type of Pump H.P. <br /> PUMP REPLACEMENT: ;/ / State Work Done <br /> FUME" REPAIR: °/ Stiate Work Done �-- - <br /> JAS JRUCTION 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 FO A'GROUT INSPECTION <br /> PRIOR TO GROUTING AND AaIN6& INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY - A6 DATE 2-3 -- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT-INSPECTION PHASE III NAL INSPECTION <br /> INSPECTION BY DATE INSPECT ON BY DATE A,� /y -r <br /> E H 1426 . Rev. 1-74 1-74 2M <br />