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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 ?7'9 <br /> "APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ?, Lc <br /> _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 /> County Ordinance No. 1862 andithe Rules a d R ulations of the San Joaquin Local Health,District. <br /> A 1(173 <br /> JOB ADDRESS/LOCATION OC CENSUS TRACT <br /> Owner's Name Lt Q„ .e- ` r Phone <br /> Address 5T City <br /> Contractor's Name e ` License # ?phone - <br /> Z <br /> TYPE OF WORK (Check) : NEW.WELL I DEEPEN/ / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION /' / PUMP REPAIR/ / PUMP REPLACEMENT /_ <br /> Other <br /> s .. <br /> DISTANCE TO NEAREST: SEPTIC TANK f SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELDS CESSPOOL/SEEPAGE PIT OTHER ' <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL " PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS v <br /> Industrial Cable Tool Dia. of Well Excavation 10, N <br /> Domestic/private Drilled Dia. of Well Casing F 7f -'- <br /> Domestic/public Driven Gauge of Casing f ; <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information 'f <br /> Geophysical , t Surface Seal Installed B : <br /> PUMP INSTALLATION: Contractor AM he—k-1v <br /> Type of Pump P. <br /> e. <br /> PUMP REPLACEMENT: / / State Work Done s. <br /> PUMP'.REPAIR: / / State Work Done <br /> DES-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 odkuin Loca�lth 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 i true to the bes my.-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR RO ING AND FINAL INSP CTION. <br /> SIGNE TITLE <br /> (DRAW. POT PLAN 'ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ��� DATE <br /> ADDITIONAL COMMENTS: <br /> r- <br /> :.PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE /b 7 d ^� INSPECTION BY DATE <br /> E H 1426 Rev. 1-74* - 3/76 2M <br />