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.: SAN JOAQUIN LOCAL HEALTH DISTRICT I <br /> FOR(OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> --.-Telephone:Telephone: k,(209) 466:-6-781 <br /> `Ai'PI,ZCATION FOR WELL CONSTRUCTION OR PUMP PERMIT /Permit No. <br /> THIS .-PERMIT EXPIRES 1 YEAR.FROM DATE ISSUED Date Issued 7r¢ <br /> v • ,(Complete In .Triplicate) <br /> Application is hereby made to the San Joaquin .Local.Health District" fox a permit to construct <br /> .and/or install the work herein described. _This application is •made •inkeompliance with 'San Joaquin, <br /> County ordinance No. 1862 .an the Rules and .Regulations-of the San Joaquin Local Health District. ! <br /> JOB ADDRESS/LOCATION <br /> } CENSUST RACT j <br /> Owner's Name ► Phone Y6 7629,/19- <br /> M. .,....,_ <br /> Address City <br /> Contractor•s Name - "` License QX,Y112 Phone, 4�( j,ZZ <br /> TYPE OF WORK (Check) NEW WELL J " DEEPEN, /- RECONDITION /7 DESTRUCTION /j <br /> ' i.PUMP.iINSTALLATION /!./''PUMP REPAIR /� PUMP REPLACEMENT f7 <br /> Other /-7 ; <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 /> IndustrialCa le Tool Dia. of Well Excavation <br /> �omestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation 1A _ Gravel Pack Depth of Grout Seal <br /> Cathodic Protection, Rotary Type e of Grout : <br /> Disposal Other Other Information <br /> Geophysical <br /> - _. .. Surface Seal Installed By; , <br /> PUMP INSTALLATION: Contractor .fZ <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /-7 State Work Done <br /> PUMP ,REPAIR-. - /77 ­S tate Work-Done <br /> PES•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 <br /> AYS -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. vell 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 N AND A F-INAhoINSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 7t <br /> ADDITIONAL COMMENTS.: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE X7 JV INSPECTION BYDATE17 <br /> 1 E H 1426 Rev. 1-74 1-7/L 9M <br />