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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> EOVOFFICE USE• ` 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> g- Jltf Telephone: (209) 466-6781 <br /> F APP ICATION FOR WELL CONST`RUCTZPN OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �4_72 <br /> (Complete In Triplicate) <br /> Application is Aereby 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_Rul s and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ` / C1 CENSUS TRACT <br /> V ff N._ ��IZAI <br /> Owner's Name .F Phone <br /> Addressw2 . CityS_4�1e,� <br /> Contractor's Name fix: e License Phone <br /> i . <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION /_ .DESTRUCTION /-7 <br /> + PUMP INSTAL TION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> { = PROPERTY' LAVE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> E INTENDED USE, TYPE .OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> h. Domestic/private ,Drilled; . . Dia.._.o.f.-We11Gasing <br /> 'Domestic/public '- Driven Gauge of Casing �r <br /> Y Irrigation Gravel Pack" Depth of Grout Seal t `v <br /> Cathodic Protection- Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> 4 PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> Il PUMP REPLACEMENT: / / State Work Done 4 <br /> PUMP ..REPAIR:. / /,,-.State Work Done. <br /> t <br />� DES•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure a' <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 GRO TI AND INAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> OR DEP TMENT USE ONLY <br /> PHASE I ` <br /> APPLICATION ACC ED BY L1 NO DATE `Z - Z Z -? <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS I /F AL INSPECTION <br /> INSPECTION BY 1,4121 DATE INSPECTION BYI�Q_ .4DATE 7 <br /> -..�- <br /> E H '1426 Rev. 1-74 -- 1Z7 2N- -- <br />