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�10 ---- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORrOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. i <br /> Telephone: (204) 466-5781 , <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. , zd i <br /> 7s-sG�-p <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued / 5' <br /> (Complete In Triplicate) <br /> Applicdtion 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 Joaquini <br /> County Ordinance No. 1862-and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �7 e r UJL L�ENSUS TRACT IM-5 2 <br /> p► <br /> Ownere s Name Phone 0 `:z <br /> Address Q '7 Cites �— <br /> y I <br /> Contractor's Name 0 License #I 2 1_3 Phone3 9 !'"' ??� <br /> TYP8 OF WORK (Check): NEW WELL DEEPEN /7 RECONDITION /7 DESTRUCTION f7 <br /> PUMP INSTALLATION fi�? PUMP REPAIR /7 PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK �Oo SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD fool CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS J <br /> Industrial X Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled 3 .Dia. of Well Casing <br /> Domestic/public DrivenGauge of-Casing -/p <br /> Irrigafion Gravel Pack Depth of Grout Seal a <br /> Cathodic Protection Rotary Type of Grout' , <br /> Disposal Other Other Information 1 <br /> Geophysical Surface Seal Installed BY: j <br /> PUMP-I..NSTALLATION: <br /> - <br /> Contractor- <br /> � <br /> ..., - . _. ._. . - _ . ... .. . ... <br /> Type of'Pump H.P. <br /> PUMP=REPLACEMENT: / / State Work Done .. . �. <br /> PUMP",REPAIR: /7 State Work Done <br /> , ES;TRUCTYON 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- well in use.. The above <br /> information is .true to the-best-of my knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GROUVW D A LIK INSPECT ON. <br /> SIGNED TITLE <br /> RAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE Il ) <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASi FINAL INSPECTION <br /> INSPECTION BY BATE / 'Z :`7S' INSPECTION BY DATE /r Z2_ 26 <br /> J <br /> .Iy <br /> } E H 1426 Rev. 1-74 1-74 2M <br />