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t <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif, <br /> _. <br /> Telephone : (209) 466--6781 - r/ <br /> I APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, �d �-37S' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued J� -�S -]1 <br /> Application is hereby made to <br /> (Complete In Triplicate) <br /> F 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 Drdinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> E JOB ADDRESSILOCATION <br /> CENSUS TRACT <br /> Owner's Name Phone ; <br /> 1 <br /> Address <br /> City <br /> Contractor's Name <br /> + L i cen s`e";ref�f�S hone <br /> TYPE OF WORK (Check) : NEW WELL / DEF,PEN /_% RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL k <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ' <br /> Industrial moble Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing z a <br /> Domestic/public Driven Gauge of Casing " <br /> Irri ation ---_Z <br /> —�� S Gravel,Pack Depth of Grout Seal <br /> Cathodic ProtectionRotar� <br /> y " '' Type of Grout <br /> Disposal Other <br /> Information <br /> Geophysical k Surface Seal Installed 13 : <br /> PUMP INSTALLATION: Contractor `A <br /> Type of Pump `" Y _„ - H.P, <br /> PUMP REPLACEMENT: / / State Work Don <br /> PUMP .REPAIR: / / State Work Done <br /> DES-TRUCT16N OF WELL: Well Diameter 1� 4 <br /> Approximate Depth <br /> Describe Material and 'Proce"dure <br /> I hereby agree to comply with a flaw andrre:gulati.ons of the San Joaquin Local Health District <br /> and the State of California pertai i7ing_ t.o or 'regulati'ri,g'we'll 'constrLiction. Within FIFTEEN DAYS <br /> after completion of my work. on a new well, I wiT"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 GRO IN D A FINAL INSPECTIO {z <br /> SIGNED <br /> -I TITLE <br /> 4DRA&PLOT PLAN ON REVERSE SIDS -" <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE /f4� <br /> ADDITIONAL COMMENTS: V <br /> _ PHASE II GROUT INSPECTION PHASE 'III/FINAL INSPECTION <br /> INSPECTION BY DATE 0 4 -INSPECTION BY DATE <br /> 11 1.426 Rev. - I-74 b/77 _ 2M <br />