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3 <br /> C., 01 a ' � SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFA CE USE: 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 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 wori 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 c94 / CENSUS TRACT <br /> Owner s Name to l S ;r Phone L <br /> Address OW-1 ;r0-jo ' 44 �Ii yp City <br /> Contractor's Name or// *It" License #13 phone 4---s, -76X <br /> TYPE OF WORK (Check): , NEW WELL -/-7 DEEPEN /"7 RECONDITION /7 DESTRUCTION /-T <br /> PUMP INSTALLATION / / PUMP REPAIR /&/ PUMP REPLACEMENT %T <br /> 'IOther /7 <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 O <br /> Industrial Cable Tool" Dia.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 /> i Disposal Other Other Information <br /> Geophysical. Surface Seal. Installed BY: <br /> PUMP INSTALLATION: ,Contractor C�� Jp► �,� <br /> 'Type of Pump H.P <br /> LZ <br /> PUMP REPLACEMENT: / j State Work Done <br /> PUMP :REPAIR: M <br /> State Work'.Done\ <br /> !� <br /> -i, , - <br /> _ <br /> ES;TRUCTION OF WELL: ,Well Diameter Approximate Depth <br />" Describe Material. and Procedure <br /> I hereby agree to complly with all laws and regulations of the San Joaquin Local Health District <br /> and the State of Cali€drnia pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of myywork on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT ofd the well and notify them before putting.. the..well in.use.. The above <br /> information is true to -the best of my wl ge an elief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO ING AN ..FINAL INSP_ _. <br /> SIGNED IE 7c ITLE <br /> II` V (D W T PLAN ON ROERSE SIDE <br /> I <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMEENTS: p, <br /> PHASE II GROUT INSPECTION P EINSPECTION <br /> INSPECTION BY I DATE INSPECTION. BY ATE <br /> E H 1426 Rev. 1-74 1-74 2k" <br />