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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOL'OFFICE USE: 1601 E. Hazelton' Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> s <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Peradt No. LLLO y <br /> j 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 Joaquin <br />� lCounty Ordinance No. 1862 and the Rules and Regulations of the San -Joaquin Local, Health District. <br /> ork <br /> JOB ADDRESS/LOCATION a 4 t ?1,2 �� �� CENSUS TRACT <br /> Owner's Name _ / iti�/�;; Y _ Phone <br /> Address city <br /> r �/ <br /> Contractor's Na V rut . License 65-0 Phone 2 Yq 54). <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN -/? RECONDITION /7 DESTRUCTION /_7 <br /> PUMP INSTALLATION f- PUMP-REPAIR /� PUMP REPLACEMENT J+ <br /> Other /_7 <br /> 4J <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE. DISPOSAL FIELD - CESSPOOL/SEEPAGE PIT OTHER r <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 /> i Irrigation ::.tip Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary -- .4 Type. of..Grout '.. -K -- --�- <br /> Disposal ', i f�� _ Other Other Information i <br /> Geophysical f ! Surface Seal`:'Tstalled By: <br />`5 PUMP INSTALLATION: Contractor <br /> YpPump --- -- - S� H.P. 1 <br /> PUMP REPLACEMENT: . '/=/-'State Work Done- <br /> PUMP :REP.—R: / / State Work Done <br /> DESTRUCTION 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 ''constructi.on. 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 FORA GROUT INSPECTION <br /> PRIOR TO GROUTING T) A INAL INSPECTION. ,. <br /> SIGNED TITLES-I10�� <br /> (DRAW PLOT PLAN ON REVERSE SIDE . <br /> FOR DEPAPTMENT USE ONLY <br /> PHASE I pr- <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECT ON <br /> INSPECTION BY -DATE INSPECTION BY DATE 2 <br /> 1 E H 1426 Rev. 1-74 r L/752M� <br />