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T SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF�;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. . 1 �c�J <br /> THIS PERMIT EXPIRES i YEAR FROM DATE ISSUED Date Issued /-ay7� <br /> (Complete In Triplicate) Q -�s'a_ z <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 -Joaquyea, <br /> Lo al Health District. <br /> 2 n epee) .S . � J� <br /> JOB ADDRESS/�.00AiION ��'�<a0lJ <br /> CENSUS TRACT <br /> Owner's blame 411 <br /> Phone _ <br /> Address 5_ city <br /> Contractor's Name License . <br /> _ . O�"!-� Phone ;-:�� <br /> TYPE OF WORK (Check): NEW WELL jg' DEEPEN '/? RECONDITION /_7 DESTRUCTION f f o <br /> PUMP INSTALLATION / / PUMP REPAIR -7 PUMP REPLACEMENT F7 ^� <br /> Other /_7 <br /> DISTANCE TO NEARE5T: 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 /> lz� <br /> INTENDED U P,(,S'px�/�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 /> f - <br /> Cathodic Protection ✓ Rotary Type of Grout A411 / <br /> Disposal Other Other Information - <br /> Geophysical Liyza - <br /> Surface Seal Installed B : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> 'UMP REPLAC_E_.MENT: . / / State Work Done <br /> PUMP `REPAIR: /7 State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> 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 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 GR TING AND A F INSF ION <br /> SIGNED s ITLE <br /> 1 Y <br /> DRAW T P ON REV SE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> / 17K <br /> ADDITIONAL COMMENTS: DATEAg <br /> PHASE 11 GROUT INSPECTI N PHASE II 7C FINAIG INSPECTION <br /> INSPECTION BY ATS G INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 _ Grr 1`rRrMll ,owo tPA ! /71� 9M <br />