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I/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOROFFICE U E: � �i 1601 E. Hazelton. Ave-i, Stockton, Calif. <br /> Telephone: ' (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION 6R'PUMP PERMIT Permit No. �6•oz3�W <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED Date Issued7� <br /> J1 (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 application is ride 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 S~ CENSUS TRACT <br /> Owner's Name (y <br /> Phone '• <br /> Address <br /> Contractor's Name <br /> ,License # Phone,51,? <br /> •II , <br /> TYPE OF WORK (Check): NEW WELL ' DEEPEN /7 RECONDITION /-7 DESTRUCTION /_ <br /> PUMPJ�INSTALLATION /� PUMP REPAIR /� PUMP REPLACEMENT f <br /> Other- %/ <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 it Cable Tool Dia. of Well Excavation / <br /> 1---Domestic/private " lDrilled Dia. of Well Casing <br /> Domestic/public 1N Driven Gauge of Casing ' <br /> Irrigation 1M Gravel Pack Depth of Grout Seal s� <br /> Cathodic Protection i! 1r Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal.Installed 'By <br /> PUMP INSTALLATION: Contractor 21e/}[. <br /> Type .af. Pumg SA,1 ACSi C,e H.P. <br /> PUMP REPLACEMENT: . /_7 State Work Done <br /> PUNK' .REPAIR <br /> / / `State Work Done <br /> D 1RUCTION OF WEL : Well Diameter � a Iiv�G Approximate Depth <br /> Describe Material and Procedure -42�,;� <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 G OUTING 'AN INAL INS CTI O . , <br /> SIGNED / k . . TITLE j <br /> (DRAW/;PLOT AN ON REVERSE SID a i <br /> 1 <br /> OR DEPAR MENT USE ONLY <br /> PHASE I li <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: s <br /> INSPECTION ByPHASE I GROU DATEECT ON'7J7 f INSPECTION gY�SE FINAL INATEECTION 4 ,E <br /> E H '1426 Rev. ,1-74 i � '- 1�/7 9th <br />