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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFirOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> /.APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> Issued <br /> Date THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DatId /p <br /> .�--�. <br /> - , - (Complete In Triplicate) <br /> Applic�tion 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 %y 2,,,;A_tU ",/Le--,'CENSUS TRACT <br /> Owner's Name - Phone �� a <br /> Address <br /> / /�- _L:i-2, /� .,.,.., ^ City � t <br /> Contractor's Naive License #/jjjZjPhone <br /> �TYP$ OF WORK (Check): NEW WELL -/7 DEEPEN /-7 RECONDITION / DESTRUCTION f <br /> PUMP INSTALLATION / / PUMP REPAIR JV—PUMP REPLACEMENT f7 <br /> Other / Aa <br /> J <br /> DISTANCE TO NEAREST: SEPTIC TANK I SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOUL/SEEPAGE- PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS h - <br /> Industrial Cable Tool Dia. of Well Excavation i <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public ,v. ;.. .� Driven "� ` <br /> a - - - -.�, .,. Gauge of Casing, <br /> Ir�ig`at3on Grave Pack Depth of GroGraut Seal j <br /> Cathodic Protection Rotary` Type offGrout � <br /> Disposal Other�� °a. Other Information <br /> Geophysical I ��, Surface "Seal Installed B <br /> PUMP INSTALLATION., Contractor <br /> Type of Pump i - ---F�,' ....._,_ ` f� <br /> . H.P. <br /> PUMP REPLACEMENT: / / State Work Done -- <br /> PUMP '.REPAIR:, :, --State Work Done )9 <br /> ES;TRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all lawsand 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 wer <br /> ll, -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 alcove <br /> information is true to the,best of- my,,knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GROYgNGa AND--A F14AL INSPEQTION. <br /> SIGNED TITLE <br /> W PLOT PLAN ON REVERSE SIDE)a <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I - - <br /> APPLICATION ACCEPTED BY . DATE <br /> ADDITIONAL COMMENTS: {ini <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 1 E H 1426 Rev. 1-74 _ 1-74 2M ._. <br />