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l <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT .` 4z� <br /> FOR.rOFFICE USE: V 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 / S <br /> (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 _ Cf L2 A P CENSUS TRACT <br /> Owner's Name j, Phone �'31S- <br /> Address ) 0 4 fCity t r7 <br /> Contractor's Name ,.�. S r� License 1-0 Phone - p"1 <br /> TYPE OF WORK (Check)-:. NEW WELL '/-7 DEEPEN /-7 RECONDITION /_7 DESTRUCTION /7PUMP INSTALLATION R/ PUMP REPAIR /_7 PUMP REPLACEMENT /7 <br /> OtherL 7 <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 /> E A <br /> PUMP INSTALLATION; Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: <br /> / / State Work Dane <br /> PUMP-:REPAIR: L� State Work Done r <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 them before putting. the. well in use.. The above <br /> information is true to the-best-of my knowledge and belief. I WILL CALL FOI& A GROUT INSPECTION <br /> PRIOR TO GtMTING AND FINAL INSPECTION. <br /> SIGNED LW.4 TITLE <br /> DRAW PLOT PLAN ON REVERSE SID <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ///,?-2z) <br /> ADDITIONAL COMMENTS: <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 />