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� [ _0 JOAQUIN LOCAL HEALTH DISTRIC <br /> 70—R"OFFICE USE: [/1(frr E. Hazelton Ave. , Stockton, CaTlf. <br /> Telephone: (209) 466-6781 <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) <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 Joaqui <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION „2(z- -Z2 4,. W 414,) M AUL- CENSUS TRACT <br /> 'timer's Name C-),(-- 1 r.S ef_ P/i Phone <br /> Address _�At4i City 4Sc1q,t0v <br /> :ontractor's Name 7 u , .� ^,.J License A ,,)79,pj Phone <br /> TPE OF WORK (Check) : NEW WELL / / DEEPEN /_7 RECONDITION /� DESTRUCTION /_7 <br /> PUMP INSTALLATION LV PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / / — <br /> )ISTANCE 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 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout r <br /> —Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump u/7 H.P. \\� <br /> PUMP REPLACEMENT: / / State Work Done C <br /> ..UMP '.REPAIR: / / State Work Done <br /> -ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> T hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> nd 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 /> nformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> RIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED a TITLEz <br /> (`i/r -. .h X77 <br /> (DRAW PLOT PLAN ON REVERSE SIDS <br /> PHASE I F EPARTMET USE ONLY <br /> dPPLICATION ACCEPTED l LI/V 6-rDATE <br /> DDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIONPHASE III F �TAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY / , DATE <br /> E H 1426 Rev. 1-74 1_74 �„ <br />