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■T SAN JOAQUIN LOCAL HEALTH DISTRICT'®` � I <br /> FORiOFFICE USE: -1601 E. Hazelton Ave. , Stockton, Calif. n: <br /> Telephone: (209) 466-6781 7 5 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No..� - <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 Nod,-1:862 a d the Rule/ and Regulations of the San Joaquin Local Health District. <br /> �7�5_ IT <br /> JO ADDRESS/LOCATII N Q 4, QQ A ! QK CENSUS TRACT <br /> Owner's"13ame;001 Phone <br /> Address /j 9 Q�, �C•' �f % C E6 A - - --- City <br /> � <br /> Contractor's Name License #,U_,4 <br /> TYPE OF WORK (Check):,/NEW WELL /ZT---15iEPEN ./_7 RECONDITION /_7 DESTRUCTION f7 <br /> PUMP INSTALLATION /G REPAIR /—/ PUMP REPLACEMENT /-7 <br /> Other / J <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES FPIT 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 ale Tool Dia. of Well Excavation /„J V �] <br /> omestic/private , Drilled Dia. of Well Casing Q <br /> F Domestic/public Driven Gauge of Casing Jf <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: lei <br /> PUMP INSTALLATION: Contractor <br /> N Type of Pump H.P. <br /> 4 <br /> PUMP REPLACEMENT: / / State Work DoneR <br /> PUMP '_REPAIR: /? State Work Done - <br /> 4 <br /> ES•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 /> G information is true to -the-best ,of my knowledge and belief. I WILL CALL FORA GROUT-INSPECTION <br /> PRIOR TO GROUTJNG AND A FIN INSPECTION. <br /> SIGNED _ y TITLE ^ <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I � '-' . <br /> APPLICATION ACCEPTED BY , DATE 9A117 <br /> ADDITIONAL COMMENTS: <br /> PHASE 11 GROUT INSPECTION /' PHAS III FINAL SPECTION <br /> INSPECTION BY DATE /,� • � INSPECTION BY A 2 <br /> �1~E H 1426 Rev. 1-74 1-74 2M <br />