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_ SAN JOAQUIN LOCAL HEALTH DISTRICT - <br /> FOErOFFICE 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 Date" Issued 9 G <br /> (Complete In Triplicate) ` <br /> Application is hereby made to the "San Joaquin Local Health District fora pditit °to construct <br /> and/or install the work herein 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 /> I <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name ow /Q Phone �� <br /> Address <br /> Cit_ - ._ ..... y.., LdzT, <br /> Contractor's Name GLS License " Phone tib <br /> -- C <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /? RECONDITION /=7 DESTRUCTION /_7 <br /> / <br /> PUMP INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT /_7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK X622 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER fn <br /> PROPERTY LINE PRIVATE DOMESTIC WELL - PUBLIC DOMESTIC WELL Vf <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS "C1 <br /> Industrial _�/Cable Tool Dia. of Well Excavation <br /> __Z,::f�omestic/private Drilled Dia. of Well Casing <br /> -- Domestic/public Driven Gauge of Casing - -• /�I <br /> Irrigation Gravel Pack Depth of Grout Seal ,oc <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed Bv: U <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP "DEPAIR: /_7 State Work Done <br /> ES.TRUCTION 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..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 UOYZ&G AND A FINAL INSPECTION. <br /> SIGNED TITLE yy/� <br /> (DRAW PLOT PLAN ON REVERSE SIDE ! <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 1 . DATE �6 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECT19 <br /> INSPECTION BY E? .f3 DATE i INSPECTION- BY DATE <br /> 1 E H 1426 . Rev. 1-74 1-74 2M <br />