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.. --0 <br /> SAN J04QUIN LOCAL HEALTH DISTRICT <br /> FOS�OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> W;A9 THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED nate Issued <br /> (Complete In. Triplicate) <br /> Application is he eby made to the San ,Joaquin Local Health District for a permit to construct <br /> rind/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 /> JOB ADDRESS/LOCATION AIS� ,G CENSUS TRACT <br /> Owner's Name Phone Z jj <br /> Address S&IS-45City ,- <br /> Contractor's <br /> ity ,Contractor's Name License # �3Dhone <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN/ RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION /5U—PUMP REPAIR -/-7—PUMP REPLACEMENT 17 <br /> Other /-7 <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 <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 B (� <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP ,.REPAIR: / / State Work Done <br /> A <br /> DESTRUCTION 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..we11. 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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Q <br /> APPLICATION ACCEPTED BY DATE ' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P E I I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY, 4ajA DATE - 30 <br /> E H 1426 Rev. 1-74 4/75 2M � <br />