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' G <br /> SAN JOAQUIN LOCAL 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. 6___ Gf' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6-3,o <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 a d Regulations of the San Joaquin Local Health District. <br /> JOB.ADDRESSAOCATION I � �- V CENSUS TRACT <br /> Owner's Name �� f Phone � U <br /> Address - City ' <br /> Contractor's NameLLJ License #14-_1-374 honezgv <br /> TYPE OF WORK Check)-. NEW WELL 77 DEEPEN 'jam' RLCOND TION /? DESTRUCTION l�"T R <br /> PUMP INSTALLATION PUMP REPAIR j PUMP REPLACEMENT /7 <br /> Other El <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 'B : <br /> PUMP INSTALLATION Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP ±REPAIR: / State Work Done`-p`�"" <br /> DESTRUCTION 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 FOR A -GROUT INSPECTION <br /> PRIOR TO GROUTING 'AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY )9DATE <br /> ADDITIONAL COMMENTS: �;/ <br /> PHASE II GROUT INSPECTION PHAS X17FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E A 1426 not, 1_7A 1.Iry e vu <br />