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f� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOBfOFPICE USE: t/ 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466 .6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. z -�,G/ <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued <br /> (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 made in compliance with San Joaquin <br /> County Ordinanc Na. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> Jr�aa j W- �rE�'� � <br /> JOB ADDRESS/LOCATION� ` i � � ���i �� r CENSUS TRACT 011- <br /> Owner I <br /> !f Owner'$ Name <br /> Phalle <br /> Address _ City <br /> Contractor's Name _ 0 ' License # Phone <br /> o� <br /> TYPE OF WORK (Check): NEW WELL &7 DEEPEN '/-7 RECONDITION /-7 DESTRUCTION f <br /> PUMP INSTALLATION / / PUMP REPAIR /-7 PUMP REPLACEMENT 17 <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: Cable Tool Dia. of Well Excavation r i <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal. <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information { <br /> Geophysical. Surface Seal Installed BY: <br /> PUMP INSTAL Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT., / / State Work Done <br /> PUMP :REPAIR: /7 State Work Done _ <br /> ES TRU&ION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <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. wdll in use.. The above f <br /> information is true to the-best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO�,U IN D A FINAL INSPECTION. <br /> SIGNED TITLE <br /> _ DRAW PLOT PLAN ON REVERSE SIDE <br /> ARTMT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPT ©LS DATE " 2O- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IIjj FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE .i��► -'7? <br /> E H 14.26 Rev. 1-74 1-74 2M <br />