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t SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR.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 /> I (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 Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION e()(� CENSUS TRACT �'Zfp_j3D_3S <br /> F <br /> � <br /> Owner's Name 4LfR T- <br /> 1 - <br /> j Phone <br /> i Addressj �r v u +,Q city amt <br /> ad <br /> Contractor's Name <br /> 1i TT Oil .Licensep - <br /> �� (�� �. hone ���Z >.} <br /> TYPE OF WORK (Check) : NEW WELL AlDEEPEN /_/ RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTALLATION /—/ — <br /> PUMP REPAIR/ / PUMP REPLACEMENT /- <br /> :Otherl / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGEDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> cb <br /> PROPERTY LINE - PRIVATE DO <br /> INTENDED USE MESTIC WELL PUBLIC DOMESTIC WELL a <br /> TYPE F WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> itDomestic/private 3 Drilled Dia, of Well Casing t f1 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation 1 Gravel Pack Depth of Grout Seal r �C <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.P. l <br /> PUMP REPLACEMENT: / / State Work Done - .i <br /> PUMP .REPAIR; to Work Dane <br /> nl <br /> �Yw DES-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 wi.11t.furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the we11 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 .G 0 I AND A FINAL,INSPECTION. <br /> SIGNED V.^' TITLE , <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I e <br /> APPLICATION ACCEPTED BY DATE 1� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PRASF/ I I/FT AL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE ��/ 7� ; <br /> E H 1426 Rev. 1-74 1177-C ,2M �f <br />