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914) <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS+1OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. za1"_.9y1Q20 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued L--? <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 wade 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 ��/` _ C� nam 7L a CENSUS TRACT <br /> Owner's Name Do 2, (-W er4 Phone <br /> Address tLo to ! W G0AAj-rLP&jr=- 12D, City <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN j-7 RECONDITION /7 DESTRUCTION /_7 <br /> f� <br /> PUMP INSTALLATION X PUMP REPAIR PUMP REPLACEMENT <br /> Other /_7 <br /> i <br /> DISTANCE 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 <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump g.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP:REPAIR: /7 State Work Done _ <br /> 2ES 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 ? <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 AND A FINAL INSPECTION. <br /> SIGNED . . - - TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 2, <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PH&SE II 1NAL INSPECTION <br /> .INSPECTION BY DATE INSPECTION BY DATE —' <br /> :� E H 1426 Rev. 1-74 1-74 2M <br />