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SAN JOAQUIN LOCAL HEALTH DISTRICT - -- <br /> FOE+OFFI E USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM-DATE ISSUED Date Issued yQ 7r� <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. 1862 and the..Rules and Regulations o€. the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONL�'� �`'-'SY� �__ - CENSUS TRACT <br /> Cj <br /> Owner's Name Phone <br /> Addresses C.� r7� �� i9 �: City ' -;9� <br /> Contractor's Name" - �CJ ls�fLicense � 173. Phone 9� ' <br /> TYPE OF WORK (Check) : NEW WELL -F7. DEEPEN -/7 RECONDITION /=T DESTRUCTION /7 <br /> PUMP INSTALLATION / f 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 /> r Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary. Type of Grout . �t <br /> -Disposal Other Other Information, <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor . <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /// State Work Donee <br /> PUMP �REPAIR: � ..„�- "- <br /> /? State Work Done <br /> jES 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 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. j <br /> SIGNED <br /> TITLE (c Yta ��� lrn� <br /> f DRAW PLOT PLAN ON REVERSE SID -- <br /> FOR DEPARTMENT USE ONLY <br /> PHASETI , <br /> APPLICATION-ACCEPTED -BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASEIII GROUT INSPECTION PH46E jjjgMqLAy <br /> ANSPECTION <br /> -INSPECTION BY DATE INSPECTION B DATE 776 <br /> H 1426 Rev. 1-»74 1-74 2M _ } <br />