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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 16C�s. Hazelton Ave. , Stockton, Calms. L <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��y O <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 the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION -5t� <br /> ��� CL CENSUS TRACT <br /> Owner's Name � � Phone <br /> A11, <br /> �fl� ' <br /> Address City ,���1t^?� p 111 <br /> Contractor's Name `,t /A.1"? �P(jalr License Phone W,-d -� <br /> TYPE OF WORK (Check) : NEW WELL/-7 DEEPEN /_/ RECONDITION /_/ DESTRUCTION /-7 <br /> AL <br /> PUMP INSTLATION REPAIR / / PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK )O- 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 F <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 Installed By: �- <br /> PUMP INSTALLATION: Contractor l` � r � ��'`97J71� <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done ' <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> qnw- <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 best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AN A FINAL INSPE 0 ; <br /> SIGNED � � TITLE <br /> D W P PLAN ON RE RSE SIM) <br /> i <br /> FO PARTMENT USE ONLY <br /> PHASE I / <br /> APPLICATION ACCEPTED BYt. }�( DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS III/]FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE - D <br /> E H 1426 Rev. 1-74 ' <br /> 3/76 2M <br />