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SAN JOAQUIN LOCAL .HEALTH DISTRICT <br /> k'ORrOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. y <br /> THIS#PERMIT -EXPIRES 1 YEAR FROM DATE ISSUED Date "Issued <br /> • - • (Complete In Triplicate) . p <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 CENSUS TRACT <br /> P ✓COY/ �f �s'e �..r. ' <br /> `/� ✓Cs � � <br /> Owner s Name Phone <br /> Address " - J� f:,;5 City i <br /> Contractor's Name Ute! 4 License 4"�3`7 ;Phoneal'Z Y <br /> TYPE OF WORK (Check): NEW WELL /� DEEPEN -/-7 RECONDITION /7 -DESTRUCTION %j <br /> PUMP INSTALLATION / / PUMP REPAIR /7 PUMP REPLACEMENT <br /> ` Other /J <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 oq <br /> INTENDED USE STYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private di. 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 BX: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Do ' <br /> 1?i1MP :REPAIR. ,.:=J State WorkDone :. <br /> &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 GROUTING AND A FINAL INSPECTION, <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> .FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY I Yo, a DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE T <br /> 1E H 1426. ., Rev. 1-74 r -_ --1-74 -2M�t '' <br />