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`� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OF CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> r <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 11--CLOLP <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1� <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. 862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> .TOB ADDRESS/LOCATI��G CENSUS TRA <br /> J CT <br /> Owner's Name Phone <br /> Address U City <br /> Contractor's Name License #/ �Y Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL /% DEEPEN/_/ RECONDITION / / DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /- <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY "# <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTX LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL 411 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> C� Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing C> <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 ctia G.� <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / ./ State Work Done L ///��� r ,� �� & <br /> _ V <br /> PUMP '.REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> 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 best of my knowledge and belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO GA441JTING ZANIDJA FINAL INSPECTI <br /> SIGNED TLE <br /> (DRA P PL ON REVERSE SIDE) <br /> PHASE I EP TMENT USE ONLY <br /> APPLICATION ACCEPTED BY -��j DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY _— DATE 7 -,2—;P]Z <br /> E H 1426 Rev. 1-74 1177 2M <br />