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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: . 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Two u/ <br /> 7q - v-43A ow <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED pate Issued F�.- <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. 1.862 and the Rules and Regulations of theZaSigui n Local Health District. <br /> JOB ADDRESS/LOCATION C SUS TRACT <br /> Owner's Name i 1 kz8uPhone <br /> Address City (� <br /> Contractor's Name LicenseC Phon 67 <br /> TYPE OF WORK (Check): NEW WELL '_W RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTILLATION KI PUMA' REPAIR /� PUMP REPLACEMENT <br /> Other /I X11 <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAI PIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TY E -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 Insta edBy: <br /> PUMP INSTALLATION: Contractor <br /> Ora"� <br /> Type of Pump H.P. <br /> R <br /> PUMP REPLACEMENT: f_1 State Work Done T <br /> PUMP ,.REPAIR: 1-7 State Work Done - <br /> ES;TRUCTION 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 /> informati true to the-best-of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G AN FINAL INSP CTION. <br /> SIGNED ".TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE)" <br /> FOR DEPARTMENT USE ONLY t <br /> I PHASE I <br /> APPLICATION ACCEPTED BY DATE f Z '� <br /> ADDITIONAL COMMENTS: } <br /> PHASE 11 GROUT=.-INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE ' .INSPECTION BY 6r, DATE <br /> R `t E H 1426 Rev. I-74 1-74 2M <br />