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SAN JOAQUIN LOCAL HEALTH DISTRICT . ,��� <br /> FOR /OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ` tfO44 ' , ' ? <br /> Telephone: (209)466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.IL.5" � /o <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Zp, su J4 <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 work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 181iond the Rules and Regulations he San Joaquin Local Health District. <br /> TRACT <br /> JOB ADDRESS/LOC N <br /> Owner f s Na / �� Phone <br /> Ci r <br /> Address 'I <br /> Contractor's Nam License , C/1__:)'3?-3hone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / RECONDITION I�I DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT <br /> Other <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 <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 /> 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. <br /> PUMP REPLACEMENT: /7 State Work Done <br /> PUMP .REPAIR: / / State Work Doi <br /> DESTRUCTION OF WELL: Well Diameter z 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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> 9]RAW PLOT PLAN ON RE FRSE SIDE <br /> F PART T USE ONLY <br /> PHASE I <br /> APPLICATION ACCE BY I/O� �lRD DATE 7A <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE '_ <br /> E H 1426 Rev. 1-74 3/76 2m <br />