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SAN JOAQUIN LOCAL HEALTH DISTRICT - - ——�- <br /> F0_WZFFICE USE. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. jG� k <br /> 7a- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued z-1,3-7&1 <br /> (Complete In Triplicate) <br /> Application is hereby made tolthe 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. 1852 and Ithe Rules and Regulations the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIO y U S l CENSUS TRACT _ <br /> Owner's Name Phone <br /> Address Cit r <br /> Contractor's Name License #AM (1 Phone <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN /_7 RECONDITION /__7 DESTRUCTION fT <br /> PUMP INSTALLATION /! PUMP REPAIR /� PUMP REPLACEMENT <br /> Other '/ / 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 L'�1 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS d <br /> Industrial I Cable Tool -Dia. of Well Excavation " <br /> omestic/private I Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation i Gravel Pack Depth of Grout S 1 C f �f <br /> 4 Cathodic Protection i otary Type of Grout <br /> Disposal t Other Other Informat on <br /> Geophysical SurfAce Seal stalled By: �• <br /> PUMP INSTALLATION Co:itractor g0,d_gZ <br /> / Type of 'Pune H.P. 4, <br /> E PUMP REPLACEMENT: / / State Work Done <br /> PUMP,!REPAIR,:_:.:. -- / -State-Work Done <br /> ,PELTTRUCTION OF_'_W_ELL: Well Diameter Approximate Depth <br /> -:Describe Mat6r1al-and-Pr6ceduYe""" <br /> I hereby agree to. comply with all. laws and-regulations of the' San, Joaquin Local Health District_ <br /> and the State of. Califorhia pertainthg_to or regulating well construction. Within FIFTEEN DAYS <br /> meter 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 /> infoY4ation is true to the—best—of my-knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR GROUTING ANDECTION. <br /> SIGNED TITLE t,/-ftZ <br /> (DRAW PLOT-PLAN-ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> P I <br /> APPLICATION ACCEPTED BY �� i DATE c "2 <br /> ADDITIONAL COMMENTS: t `- <br /> PHASE II GROUT INSPECTION PHA I NSPECTI N <br /> ' <br /> INSPECTION BY f DATE INSPECTION B TE <br /> )49V <br /> 1 <br /> 1=74 2M <br /> E H 1425 Rev. �74 k <br />