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XY SAl JOAQUIN LOCAL HEALTH DISTRICT <br /> FOPirOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209)1466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.,� 39d 4 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> ;fig S a , fir:`' r d; n{~'i .t1 (Complete In Triplicate) C)ems` �CyD S'� <br /> Application is hereby'made to the San Joaquin Local Health District for a permit to c6nstruct <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 Jo�aqguin Local Health District. <br /> _74 <br /> JOB ADDREss/LocATION 4. cENsys TRACT <br /> Owner's Name Phone <br /> Address y City <br /> Contractor'a Name <br /> LicensePhone <br /> J _ <br /> TYPE OF WORK (Check): NEW WELL '/ DEEPEN RECONDITION /_7 DESTRUCTION./ <br /> PUMP .INSTALLATION / PUMP REPAIR / PUMPRLPLACEMENT <br /> i <br /> Otlieit; # <br /> NDISTANCE TO NEAREST: SEPTIC TANKRSEWER LINES `PIT PRIVY -�- - ,j <br /> SEWAGE DISPOSAL FIELD — --C SPOOL/SEEPAGE PIT /00 -,X-OTHER"-- <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL/`��"PUBLIC DOMESTIC WELL ......a'0 ° <br /> E <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS tri <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of .Well Casing <br /> w ` Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> E __ <br /> Disposal ' Other Other Information <br /> j Geophysical Surface Seal Installed By: <br /> lot <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump "05 ' H.P. _ ..— •• <br /> PUMP REPLACEMENT: / / State Work Done . <br /> . PUMP 'REPAIR: /7 State Work Done - -- <br /> ES TRUCTTON OF WELL: Well Diameter Approximate Depth _ <br /> lZescribe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> k 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 FORA GROUT INSPECTION <br /> PRIOR T'O .GROUTING AND A FINAL INSPECTION. <br /> SIGNED.. = TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ` ifJ�� DATE <br /> ADDITIONAL COMMENTS: <br /> PHAS II R T INSPECTI PHASFr I INSPECTION <br /> INSPECTION BY DATE INSPECTION ;BY E <br /> ,, .. � _ <br /> E H 1426 Rev. 1-74 - 1-74 2M <br />