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T 1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR O FICEUSE: ' 'r 1601 E. Hazelton Ave. , .Stockton, Calif. <br /> D , Telephone: (209) 466-6781 �� S <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 /> f Applica'tion'is' 'Aereby 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-M .I � � � <br /> CENSUS TRACT <br /> Owner'sName 1 �- � � Phone/ .`��" �. 2-1. <br /> Address Cit <br /> y. <br /> Contractor's Nam Licens/ ?3 Poor 1� <br /> Ipp _ I <br /> TYPE OF WORK (Check) :. NEW WELL / < DEEPEN /77. ,RECONDITION/ DESTRUCT=ION /7; -., <br /> PUMP INSTALLATION / `/ PUMP REPAIR /N( PUMP REPLACEMENT <br /> ' other <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 We'll",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 I Other Other Information <br /> Geophysical � . Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Doge <br /> - <br /> `PIINlP '�REPATRs— � �t State Work -Dane <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> T Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health istrict <br /> and the State of California pertaining to or regulating well construction. Within FIF'T'EEN DAYS <br /> after Completion of my ;rwork on a new well, I will furnish the San Joaquin Local. Health District a <br /> WELL DRILLERS REPORTof£ the well and notify them before putting the well in use. The Above <br /> information is true tol�the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A. FINAL INSPECTION. <br /> SIGNED 10 , i TITLE ' <br /> _== iM DRAW PLOT PLAN ON REVERSE SIDE) <br /> .FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APCATION ACCEPTED BY DATE <br /> PLI , <br /> ADDITIONAL COMMENTS: ,t Mt <br /> PHASE II GROUT INSPECTION PHASF,III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY � ( .DAT r� <br /> FfT/ <br /> �. � or <br /> E H1426 Rev. 1-74 . �"�s � �` c {� � 1/7.7.. � .� 2�*, <br />