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SAN JOAQUIN LOCAL HEALTH DISTRICT f <br /> FOR_ OFFICE USE: 1601 E. Hazelton Ave. , .Stockton, Cali <br /> Telephone: (209) 466-6781 y� Ze <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT ermrt No. Q <br /> THIS PERMIT. EXPIRES 1 .YEAR FROM DATE ISSUED Date -Issued. <br /> (Complete In Triplicate.) <br /> Application is hereby made tol 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. 1$62 :an 41 the, Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION g, Aue CENSUS TRACT <br /> Owner's Name ` Phone — oC <br /> 6 ZY <br /> Address m .. !. CI ho <br /> ity.. <br /> ' ..-� License #Z;? �o Phone <br /> Contractor's Name � t v� <br /> TYPE OF WORK (Che k. ) : NEW WELL f7/ DEEPEN / / RECONDITION_/ / DESTRUCTION <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT / <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC ,'TANK SEWER LINES PIT PRIVY l`+ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER w <br /> PROPERTY LINE _ PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> E INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial i Cable Tool Dia. of -Well Excavation <br /> Domestic/private l Drilled Dia. of Well Casing qzs <br /> omestic/public i Driven Gauge of Casing . <br /> rrigatio-n Al Gravel Pack Depth of Grout Seal T r� <br /> Y Type of Grout <br /> Rotar T <br /> Cathodic Protection <br /> .. <br /> Disposalr . Other Other Information X <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: = Contractor : T a/ <br /> Type of Pump H.P. ' /Q <br /> PUMP REPLACEMENT: / / State Work Done <br /> T <br /> PUMP .REPAIR: - Y / / State Work Done <br /> DESTRUCTION 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 GROU NG AND A FI L I SPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> 12 FOR DEPARTMENT USE ONLY <br /> PHASE I ' <br /> APPLICATION ACCEPTED BY /AiDATE ` ? <br /> ADDITIONAL COMMENTS: ,�� <br /> PHASE•'TI GROUT,tINSPECTION PHAS II/FI INSPECT�ON , <br /> INSPECTION BY DATE INSPECTION BY ATE '7 <br /> b/77 _ 2M <br /> ­F H 1426 Rev. . 1-74 <br />