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SAN JOAQUIN LOCAL BEALTH DISTRICT <br /> s FOF�:OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> �;, Telephone; (209) 466-6781 7S-S4•f� <br /> f' APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. r _ <br /> f <br /> THIS.PERMIT EXPIRES 1 YEAR FROM DATE ,ISSUED Date Issued �D <br /> (Complete In Triplicate) <br /> Application is hereby made, to the Son 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 Jonquir <br /> County Ordinance No. 1862 and the Rules and Regulations of the Saar Joaquin Local Health District, <br /> JOB ADDRESS/LQCAT ON 3:57 � /hq x, f_ CENSUS TRACT„ <br /> L.. PhoneW-� <br /> i, Owner's Name <br /> f orf 1 - .� _ .Tz✓�� .. City�'7��+��I°`.� <br /> Address <br /> �-�� � <br /> Contractor's �� <br /> Name � �� U � � License �� <br /> ' 3hone -.-y`' <br /> - <br /> TYPE OF WORK (Check) : NEW WELL '/_7 DEEPEN -/7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTLATION I J PUMP REPAIR /�, PUMP REPLACEMENT /? <br /> AL <br /> E Other /_7 <br /> {DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER L <br /> PROPERTY LINE --PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Took. 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 H.P. �11 <br /> - i <br /> PUMP REPLACEMENT:'. / / State Work Done _ <br /> PUMP -REPAIR: / State Work Done <br /> f <br /> DESTRUCTION OF WELLS 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 c DATE , I <br /> APPLICATION ACCEPTED BY <br /> ' ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTInw P E I FINAL INSPECTI <br /> INSPECTION BY DATE INSPECTION BY ' DATE <br /> i <br /> 4. 2M <br /> R H TA26 RAA. 1--74 �f <br />