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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> 'FOr,?' FFICE USE` 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> r APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �'- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued / T�! <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.' 1862 and th% ujej an Rq&ulatiolls of the San Joaquin Local Health District. <br /> i <br /> JOB ADDRESS/LOCATION . I NSUS TRACT <br /> Owner's NameAPhone <br /> r <br /> Address City <br /> Contractor's Name License # ��7 �-- hone <br /> Z)" <br /> TYPE OF WORK (Check) : NEW WELL / DE_E_PE_N / _/ RECONDITION- DESTRUCTIQN-IT <br /> PUMP INSTALLATION / / PUMP, REPAIR PUMP ,REPLACEMENT <br /> _j777:t - <br /> DISTANCE TO NEAREST: SEPTIC TANK f SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD C SPOOL/SEEPAGE PIT OTHER �G <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> f <br /> ENDED USE TYPE O LL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation �iD/1 rl <br /> a omestic/private Drilled Dia. of. Well Casing. rl <br /> Dome stic/pablic Driven Gauge'of­Cas" ng' ' <br /> ' Irrigation Gravel Pack Depth of Grout Seal 1 <br /> 'Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Informations +- <br /> 4Geophysical _ Surface Seal Installed By: <br /> F. dr <br /> PUMP INSTALLATION: Contractor <br /> s Type:of Pump <br /> PUMP REPLACEMENT: / / ' State Work Done <br /> ..PUMP .REPAIR: / / State Work Done , <br /> -I. 9 °' <br /> DESTRUCTION OF WELL: WelliDiameter .' Approximate Depth <br /> Describe Material and Procedure i i <br /> it i = <br /> I hereby agree to comply with`all7law6aria regulations'of the'San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well ''cons.truction. Withi.n'FIFTEEN DAYS <br /> after.'_completion of my work on A, nei;�well, I will furnish the San Joaquin Local Health District a <br /> , WELL DRILLERS REPORT of the wellYand not them before pu0'ti:ng the well in use. The above <br /> information is ue to the be's.t )myfknotledge and belief. I WILL C L FOR A GROUT INSPECTION <br /> PRIOR'+TO GROU I AND FINAL PECT 0 <br /> bwj <br /> SIGNED '449 <br /> TITLE r <br /> t DRAW P PLAN ON REVERSE SIDE) <br /> FOV DEPARTMENT USE ONLY <br /> 4 PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> , ADDITIONAL COMMENTS: <br /> ' PHASE II GROUT INSPECTIO PHASE I /FIN INSPECTI Nr <br /> ' INSPECTION BY DATE ,14`7 INSPECTION BY DATE <br /> 1/7T . 2M 4, <br /> F H 1426 Rev. 1-74 <br />