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-c <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFRrOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. / <br /> Telephone: (209) 466-6781 -71 rf 5� <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) - 44 <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 com lia th San Joaquin <br /> County Ordinance No. 3$62 and the Rules and Regul 40717 SAYnan1Lth District. <br /> JOB ADDRESS/LOCATION <br /> ,2p-1—7-d Al A CENSUS TRACT <br /> Owner's Name .S Phone U��,!57`F_ h <br /> �— <br /> Address 44eazxCity If <br /> Contractor's Name License #.L%jW Phone <br /> TYPE OF WORK (Check): NEW WELL /ZT--DEEPEN �/-7 RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION jL— UMP REPAIR /-7—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 Well Casing r <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal `: <br /> Cathodic Protection Rotary Type of Grout <br /> 4- / <br /> Disposal Other _ � Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor ` <br /> Type of Pump '40"T.P. <br /> PUMP REPLACEMENT: / / State Work Done E <br /> PUMP :REPAIR: /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 /> information is true to the-beat of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO NppAND A FIN PECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY . DATE &0 d <br /> ADDITIONAL COMMENTS: Ir <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECT12 <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 �. 1-74 2M <br />