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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOArOFFICE 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 /> (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/LOCAT_ 10N. .2 „r. CENSUS TRACT <br /> Owner's Name� .� ew. L1.., .�. <br /> Phone LZR-- 2FL27 <br /> Address <br /> city 'C' <br /> Contractor's Name Licenses? p,JQ Phone <br /> 1 q <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN /7 RECONDITION /7 DESTRUCTION /-7 <br /> 1 PUMP INSTALLATION /7 PUMP REPAIR .lel PUMP REPLACEMENT % F <br /> Other' / I — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES` t PIT PRIVY � <br /> �" p <br /> �'"'"SEWi(;E DISPOSAL FIELD -CCS PIT OTHER N <br /> F PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED -,USE TYPE OF WELL <br /> I CONSTRUCTION SPECIFICATIONS <br /> Industrial t Cable Tool Dia. �of Well Excavation <br /> DomesticJprivate k .Drilled Dia. oftWell Casing <br /> Domestic/public. c _Driven .-�- .__Gauge of, Casing <br /> Irrigation t Gravel Pack Depth of �IGrout Seal <br /> Cathodic Protection I Rotary Type ,of ,Grout <br /> Disposal Other Other Information <br /> `r Geophysical �.�.�. . .�.. __._ __. <br /> tt;.. I r.t _ �„ 'Surface Seal Installed'B : <br /> PUMP INSTALLATION: �-` <br /> Contractor. <br /> Type of Pump H.P. s <br /> _ . . -- <br /> PUMP REPLACEMENT: / / State Work Done _ y. ' <br /> PUMP`:REPAIR.- �p State Work Done <br /> ES-TRUCTION OF WELL: Well Diameterp� f'v•�py �� <br /> t - Approximate-Depth <br /> Describe Material and Procedure j <br /> 7. <br /> I hereby agree to comply with all laws and regulation's of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulat,irig 'wellconstruction.`”' 'W' ithin -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 befo e .putting. the. weli in-use.. The above <br /> information is true to the-best of my-knowledge and &!lief. I WILL CALL' FOR 'GROUT INSPECTION <br /> PRIOR, TO G TING AN AL INSPECTION. t <br /> SIGNED TITLE <br /> - DRAW-.PLOT-PLAN-ON-REVERSE SIDE <br /> •':',:t;� �;, -✓I s i FOR DEPARTMENT USE ONLY <br /> F <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> DATE . <br /> ADDITIONAL COMMENTS: ' <br /> PHASE II GROUT INSPECTION PRASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 I-74 2M <br />