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SAN JOAQUIN-L,OCAt HEALTH DISTRICT <br /> FO&`OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �'�- 2Z 4,) <br /> THIS PERMIT E)T IRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> i' Application is hereby made to the San Joaquin Local Health District for a permit to construct y <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 /> g93 q . <br /> JOB ADDRESS/LOCATI044 - QG' CENSUS TRACT <br /> f r4. <br /> Owner's Name Phone <br /> Address Q <br /> City , <br /> Contractor's Name i <br /> icense #,,2k /3Phone <br /> TYPE OF WORK (Check): NEW WELL LIV DEEPEN '/? RECONDITION 17 DESTRUCTION /7 <br /> PUMP INSTALLATION /7 PUMP REPAIR 1_7 PUMP REPLACEMENT rf <br /> Other / ./ <br /> DISTANCE TO NEARE T: SEPTIC TANK f 1 O SEWER LINES PIT PRIVY 1 <br /> SEWAGE DISPOSAL FIELD Z�Q Q CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE .- PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDS 5E 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 ProtectionRotar <br /> l. �.� y Type of Grout <br /> -Disposal __���m;,ua�� � ,,...• ,_ . <br /> Other -Other-Other Information <br /> Geophysical Surface- Seal installed By: <br /> PUMP INSTALLATION: Contractor . <br /> Type of Pump E <br /> H.P. <br /> PUMP REPLACEMENT: <br /> / / State Work Done } <br /> _PUI�_:REPAIR-'- --=-- . . .L7z_-State-Work Done-, <br /> ES;TRUCTION OF WELL: <br /> 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 f <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 g <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 /> PRLOR TO GROUTING AND F AL INSP GT�ON <br /> SIGNED TITLE <br /> (DRAW T P ON REVERSE SID . ; <br /> R DEPARTMENT USE ONLY � <br /> PHASE I <br /> APP LIGATION ACCEPTF BY � �j -7 <br /> ADDITIONAL COMME HATE <br /> P 4& G UT INSPECTION P S I INAL INSPECT ON <br /> INSPECTION DATE INSPECTI BY DATE <br />�; a 1426 Rev. I-74 <br /> r - 1-74 2M <br />