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SAN JQAQUIN LOCAL HEALTH DISTRICT ' _ --- <br /> FORiO CE USE: <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES I 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 /> County Ordinance No. U62 and the Rules and Regulations of the San Joaquin Local Health Dand/or install the work herein described. This application is made in compliance with San Joaquin <br /> istrict. <br /> .TOB ADDRESS/LOCATION ` f yv NSUs TRACT <br /> Owner's Name wimp tt_ Phone <br /> Address �} <br /> City <br /> Contractor's Name License { /"Phone <br /> TYPE OF WORK (Check): NEW WELL/ DEEPEN / <br /> _/� RECONDITION /7 DESTRUCTION /`j <br /> PUMP INSTALLATION / / PUMP REPAIR <br /> Other /_7 Z>01 PUMP REPLACEMENT - <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 7" i <br /> SEWAGE DISPOSAL FIELD CE9`ST'OOL/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 /> _ <br /> Domestic/public Driven Gauge of--Casing E <br /> � Irrigation Gravel Pack Depth ofGroutSeal <br /> Cathodic Protection Rotary Type of Grout' <br /> -Disposal Other _ Other Information <br /> Geophysical Surface Sea] Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. �• " C7 �� <br /> PUMP REPLACEMENT: // State Work Done <br /> PUMP :REPAIR: / State Work Done �d i <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 best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRPUKNG AND A FINAL INSPECT <br /> SIGNED sja� <br /> /71 {DRAW P E <br /> FRSE S <br /> PHASE I PART MEN T USE ONLY <br /> APPLICATION ACCEPTED BY / <br /> ADDITIONAL COMMENTS: DATE 3 r <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY _ DATE I <br /> 0 <br /> E H 1426 . . Rev. .1-74 <br /> 1-74 2M <br />