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t <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: ' 1601 E. Hazelton Ave. , Stockton, Calif. <br /> I :, Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, ,7� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issuedt // <br /> 00, <br /> (Complete In Triplicate) <br /> Application is 4ereby made t _I the San Joaquin Local Health District for a permit to construct <br /> and/or install the woje described. This application is made -in compliance with San Joaquin <br /> County Ordinance No, the Rules and Regulati s of the San Joaquin Local Health District. <br /> LIU <br /> JOB ADDRESS/LOCATICENSUS TRACT 19P"t)2©--07 <br /> Owner's Name 01 <br /> Phone �(� <br /> Address <br /> Contractor's Name License � p� <br /> #eo �a(7C1 Phone �•3" <br /> i <br /> TYPE OF WORK (Check) :, NEW WELL/ f DEEPEN / / RECONDITION f_1 DESTRUCTION /_7 <br /> PUMP INSTALLATION -mak` PUMP REPAIR /% PUMP REPLACEMENT 'I <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY _LINE -- .PRIVATE-DOME STI,C WELL. PUBLIC DOMESTIC-WELL_' <br /> INTENDED USE t TYPE-OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial - - —. <br /> ; "`�" "'•Cable-Toll Dia. -of' Well 'Excavation` <br /> Domestic/private 1 Drilled Dia. of Well Casing <br /> Domestic/public- A Driven Gauge of Casing <br /> Irrigation '„ 6 :� Gravel Pack Depth of Grout Seal <br /> Cathodic Protection 1 Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: . <br /> �c�+ <br /> PUMP INSTALLATION: Contractor �� ��� <br /> - Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,REPAIR: / / State Work Done <br /> �Tlb <br /> LES•TRUCTION -OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 7 s <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 GRO TING AN FINAL INSPECTION. <br /> SIGNED TITLE _ <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I a <br /> APPLICATION ACCEPTED BY -- DATE T/ Z-7 <br /> ADDITIONAL COMMENTS: i <br /> PHASE II GROUT INSPECTION PHASE FINAk INSPECTION <br /> INSPECTION BY -DATE INSPECTION BY DATE <br /> E H 1426 Rev, 1-74 <br /> 1177 2M <br />