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v SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF�.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone; (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ?,; � <br /> ;Z3 Q�b-p ";E Date Issued <br /> 6� �9- vz-c7 Q �. ! (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for permit to onstruct <br /> and/or install the work heroin 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 /> Jos ADDRESS/LOCATION <br /> SUS TRACT <br /> Owner's Name - u , <br /> Phone <br /> Address <br /> CitySYK <br /> may..,. <br /> Contractor's Name <br /> Licensees Phone -Q(F <br /> d <br /> TYPE OF WORK (Check): NEW WELL ',K DEEPENI-7 RECONDITION / f DESTRUCTION /_7 <br /> 4 <br /> PUMP INSTALLATION� PUMP REPAIR /-7 PUMP REpLACEMEjff <br /> Other / 7 <br /> ro <br /> DISTANCE TO NEAREST: SEPTIC TANKS <br /> SEWER LINES PIT PRIVY (b <br /> SEWAGE DISP SAL FIELD CESSPOOL/SEEPAGE PIT p OTHER (�1 <br /> PROPERTY LINE _ PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE T�Wool <br /> CONSTRUCTION SPECIFICATIONS <br /> Industrial TDia. of Well Excavatio: <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public �- <br /> �� Driven Gauge of Casing _, <br /> Irrigation _ Gravel Pack Depth of Grout Seal <br /> Cathodic Protection _ Rotary <br /> Type of Grout C <br /> _,Disposal �� other Other Information t° <br /> Geophysical Surface Seal Installed 'B : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: ,,,. / / . State Work Done <br /> PUMP '.REPAIR: <br /> /? State Work Done <br /> DESTRUCTION OF WELL: Well Diameter. <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply with all laws and regulationsof 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 "e well and notify them before putting-the-well in.use.... The above <br /> information is true o the-best-of my..knowledge and belief. I WILL CALL FOR A 'GROUT INSPECTXON <br />'RIOR TO GR I IO <br /> Amr <br /> SIGNED <br /> TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL CONMENTS: DATE <br /> PHASE II GROUT INSPECTION PHASE I FINAL INSPECTI N <br />[NSPECTION BY DATE - 3 o-1-'7INSPECTION BY , <br /> . DATE- 2 <br /> E H 1426 Rev. 1-74 M,/�r <br />