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SAN JOAQUIN LOCAL HEALTH DISTRICT --- <br /> FORt'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. X41 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issue <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 hereiii.. 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 Oe - CENSUS TRACT <br /> Owner°s Name Phone3 9YA <br /> ,-F-17 I? <br /> Address <br /> City <br /> Contractor's Name License # <br /> &,j2 Phone Z i <br /> TYPE OF WORK (Check): NEW WELL -/XT—_DEEPEN -/_7 RECONDITION /_7DESTRUCTION ` <br /> t 'PUMP INSTALLATION /�UMP.REPAIR //7/. PUMP REPLACEMENT /7 <br /> . Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FT LD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL ». CONSTRUCTION SPECIFICATIONS O <br /> Industrial A--,Cable Tool Dia. of Well Excavation r/ <br /> a----#?ocnestic/private Drilled Dia. of Well Casing f <br /> Domestic/public Driven Gauge of Casing / 1 <br /> t Irrigation Gravel Pack Depth of Grout Seal#' � 4"71 <br /> Cathodic Protection Rotary Type of Grout '�[ <br /> Disposal Other Other Information �. ..,_,�... <br /> Geophysical Surface Seal Installed By- <br /> PUMP <br /> •PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: /_7 State Work Done - <br /> ES1RUCTION 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 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 GRO ING AND A F'I AL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) _ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 3x <br /> APPLICATION ACCEPTED BY rt DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE It GROUT INSPECTION PHASE III FINAL INSPECTIOPF <br /> INSPECTION BY DATE f 0 .Z. INSPECTION BY DATE / .a 7X <br /> C472~E H 1426 Rev. 1-74 i_�[. M-' <br /> ? <br />