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SAN JOAQUIR' ;L'CAL HEALTH DISTRICT <br /> FOS.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> I <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> j (Complete In Triplicate) <br /> Application is -hereby made to the `San Joaquin Local Health District for a permit to construct <br /> and/or instar, the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rule and Regulations of t an Joaquin Local Health District. <br /> r <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name 9&A-4 Phone c�3 6 f <br /> `Address 26 'el <br /> City 'I ,� <br /> Contractor's Name <br /> License #cQ2Q Phone <br /> TYPE OF WORK (Check) ; NEW WELL f7 DEEPEN /_7 RECONDITION /_7 DESTRUCTION f7 <br /> PUMP INSTALLATION I I PUMP REPAIR/? PUMP REPLACEMENT /7 <br /> Other /% --- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> i <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 U <br /> Domestic/public i Driven Gauge_of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal . <br /> Cathodic Protection I �Rotary Type of Grout <br /> -Disposal <br /> Other Other In <br /> Geophysical- '- Surface Seal Ins tailed 'B :; <br /> PUMP INSTALLATION: Co <br /> ntractor <br /> Type of Pump <br /> i H.P. - <br /> PUMP REPLACEMENT: . / / State Work Done - <br /> -State <br /> one - <br />.PUMP '1tEPAIR:-_ FWork- Doner/_ -State <br /> � p <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth y <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.knowled and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR OUTING AND Nps, 1 p N. <br />,SIGNED , <br /> E.. <br /> Ze <br /> D W PLOT PLAN ONREVER SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION' ACCEPTED BY <br /> ADDITIONAL COMMENTS: f DATE k 1-01 Vi-°1 S <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY <br /> 7 N -. <br /> Ell 1426 ' Rev. 1-74 <br />