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C SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 0R!.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7-s-��o21c1 <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 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION / , /� �tf CENSUS TRACT <br /> r Owner's Name Phone t9 '-30- <br /> Address 2 - City <br /> Contractor's Name - _ License # ' &/):Z Phone A16Z.-.5�5­9'7 <br /> TYPE OF WORK (Check) : NEW WELL_ ..DEEPEN /7- RECONDITION- /_7 DESTRUCTION r7 <br /> f PUMP INST:A,LLATION / / PUMP REPAIR /_7 PUMP REPLACEMENT /_7 <br /> .` <br /> Oiher / / '1 <br /> �r <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 /> INTENDEDIUSE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial it Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing r 9: <br /> Irrigation L Gravel Pack Depth of Grout Seal .� 60...^ <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 ,. . H.P. <br /> PUMP PREPLACEMENT: Ll State Work Done <br /> PUMP 'REPAIR: /_7 State Work Done - <br /> PES4RUCTION 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: af_my -Work on a new well, vI will .furnish the SanJoaquinLocal 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 GROUTI D A INAL INSPECTION. <br /> I SIGNE4o/ TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I (�� � � � _ <br /> APPLICATION ACCEPTED BY DATE ^lot S <br /> ADDITIONAL COMMENTS: <br /> PHASE I GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE -Yo- . S'� INSPECTION BY i"' DATE �., p a7 <br /> 5 , <br /> ~E H 1426 . . Rev. 1-74 __ 1-74 2M .�-a <br />