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I <br /> r SAN JOAQUIN LOCAL REALTH DISTRICT <br /> FOF� OFFICE 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 <br /> (Complete In 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 Ordinance No, 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 'a t {� �G[-/?� CENSUS TRACT <br /> Owner's Name Phone <br /> Address "r! 4G / (•� (.G YYI City l �y <br /> Contractor's Name License # JL42k ae <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /-7 RECONDITION /-7 DESTRUCTION <br /> j PUMP INSTALLATION / / PUMP REPAIR j/ PUMP REPLACEMENT /7 <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 <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 INSTALLATION: Contractor <br /> Type of Pump h H.P. Z <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'REPAIR: 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 the ore puttingthe- well in use.. The above <br /> information is true to the-best6T--m* nowAZd e an elief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO U ING AN A FINAL IHinCTIO . <br /> SIGNEDTLE <br /> D PLOT PLAN ON REV9RSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED - DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III NAL INSPECTI-N <br /> INSPECTION BY DATE INSPECTION BY ATE <br /> <. <br /> co <br /> `I :E H 1426 Rev. 1-74 `' <br />