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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO. OFF-1-CT USE: 1601 E. Hazelton Ave. , Stockton, Calif. p <br /> Telephone: (209) 466-6781 2 -7 - <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No7 2—1150-./1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued op- A-2 <br /> • r <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 thework herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1.862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION o _ CENSUS TRACT <br /> Owner's Name dc. a„ Phone <br /> Address City <br /> Contractbr`'s 'Name`.�.A - <br /> 1 <br /> i, censePhone� <br /> i <br /> TYPE OF WORK (Check) : NEW WELL /�EPEN / / + RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION / / PUMP, REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST:- SEPTIC TANK/&e4- SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE PRIVATE DOMES-T-IC-WELL.-. ._PTJBL-TC--BOMESTIC WELL <br /> INTENDED USE s TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> I dustrial Cable Tool Dia, of Well Excavation J�,t <br /> Domestic , <br /> /private Drilled Dia. of Well Casing <br /> Domestic/public Driven `. Gauge ofT .Casing _ <br /> .irrigation Gravel Pack - , Depth of Grout Seal . <br /> _Cathodic Protection Rotary :- Type of GrouC` .. - _ ^t <br /> Disposal Other . Other Information <br /> Geophysical 4 Surface Seal Installed By: <br /> PUMP-INSTALLATION: Contractor <br /> 4- Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> ee c <br /> PUMP .REPAIR: / / State Work Done �- ---^• -^ `" '^ " ' 1 <br /> s <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> Thereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to ox 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 /> PRION TO GROUTING AN A114Ak <br /> INSP <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/...FINAL INSPECTION r <br /> INSPECTION BY DATE INSPECTION BY DATE J/- -c� <br /> E H 1426 Rev. , 1-74 s - b/77 _ 2M <br />