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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazkton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � <br /> s v <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> 5� I (Complete In Triplicate) <br />` Application is Aereby 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. Y862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/L�CATIONZMA <br /> :L_4 Z&SUS TRACT <br /> Owner`s Name ` <br /> Phone <br /> Address d t, <br /> City s <br /> Contractor's Name _t26 —� <br /> License Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN' <br /> RECONDITION--' /—/ DESTRUCTION 1-7 <br /> _ <br /> PUMP INSTALLATION / / PUMP REPAIR pip REPLACEMENT <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES250 PIT PRIVY <br /> SEWAGE [fir <br /> DISPOSAL FIELD ap CESSPOOL/SEEPAGE FI'f !� OTHER <br /> PROPERTY LINH'DPRIVATE DOMESTIC WELL�1 PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> IndustrialIX = <br /> Cable, <br /> Tool Dia, of Well Excavation <br /> r O d <br /> Domestic/private Drilled Dia, of Well Casing ai <br /> Domestic/public i Driven Gauge of Casing <br /> Irrigation ! Gravel Pack Depth,.of"Grout Seal r <br /> Cathodic Protection . Rotary TypeF of-Trout! Other "l Other Information <br /> Geophysical _ .�- ` <br /> t 1- Surface Seal Installed By: <br /> PUMP INSTALLATION: .,. , Contractor <br /> rt <br /> Type of Pump ;. / a ,ti•� ! H.P. 1-2 <br /> PUMP REPLACEMENT`' .�~ (,t/ �� � ,✓� <br /> / / State Work Done <br /> PUMP 'REPAIR; /_/ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> ' Describe Material and Procedure Approximate Depth <br /> M <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 on1a. new well, T 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 •s <br /> information is true to t b t f my knowledge and belief, I WILL CALL FOR A GROUT INSPECTION- <br />'RIOR TO G b A, I ECTION. <br /> 5IGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE, I <br /> 0LICATTON ACCEPTED BY <br /> AD •DATE .L <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/,FINAL INSPECT ON <br />[NSPECT.ION BY DATE ✓ INSPECTION BY DATE ,J <br /> f <br /> r <br />'—E,H 1426 Rev. 1-74 . _ .. 1777 . <br /> ft <br />