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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F-0944-F CE USE: V11"'1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. S-O <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued Z,5-- <br /> (Complete <br /> S(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, 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 2 S 3 CENSUS TRACT <br /> Owner's Name a S Phone <br /> Address City <br /> Contractor's Naive � . License # dA 7,-,4—Phone 416� <br /> 60, <br /> TYPE OF WORK (Check): NEW WELL /-7 DEEPEN /-7 RECONDITION /-7 DESTRUCTIONJ7 <br /> PUMP INSTALLATION / / PUMP REPAIRI�C� PUMP REPLACEMENT /T <br /> Other / I <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 k H.P. 7/;; <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: State Work Done - a � �. <br /> 4ES TRUCTION OF WELL: 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 Focal 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 4ROUTING MD ,A FINAL INS I <br /> SIGNED ) .' ITLE <br /> �i LO ON ERSE SIDE—� <br /> ,4 OR T USE ONLY <br /> PHASE I r <br /> APPLICATION ACCEPTED B DATE <br /> ADDITIONAL COMMENTS: ' <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 1 E H 1426 Rev. 1-74 1-74 2M <br />