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r <br /> r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR 14OFFIG USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> i 11 Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> �f <br /> THIS PERMIT EXPIRES I YEAR FROM-DATE ISSUED Date Issued �� I <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 of the San Joaquin Local Health District. ,"] <br /> . JOB ADDRESS/LOCATION CENSUS TRACT. <br /> Owne'r's Name - Phone <br /> e <br /> Address a i's L4 q City <br /> Contrat <br /> cor' Name ame ## a� i <br /> 4 �lC�LLLL�.� 9-,F. � ,lj . Y. License # � Phone <br /> TYPE OF WORK (Check) : NEW.WELL DEEPEN '/ / RECONDITION / / DESTRUCTION <br /> t �< PUMP-1VETALLATION f i tPUMP-REPAIR"7%""PUMP"REPL'ACEMENT <br /> Her <br />', DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES Ion PIT •PRIVY <br /> SEWAGE DISPOSAL FIELJ)--_�±, i ',CES'SP6OL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL_ <br /> .INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial =-X Cable Tool Dia. of Well Excavation \ ' <br />- Domestic/private Drilled Dia. of Well Casing' <br /> Domestic/public Driven Gauge of Casing j� <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> .Cathodic Protection 1 Rotary Type of Grout 77 <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B ' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ' <br />'PUMP REPLACEMENT: / / State Work Done <br /> PUMP .R2PAIR; / / State Work Done <br /> i <br /> DESTRUCTION OF WELL: Well DiameterApproximate Depth + <br /> Describe Material and Procedure <br /> ' 4 <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 11 -'c•bii`struction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish .the=SanV`Joaquin; Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putt,g�'the. well in use.:.. The above <br /> information pis true to�-the-best of my knowledge and.beli.eI W,I L CALL FOR A GROUT INSPECTION <br /> PRIOR TO G OUTING AN#- A FINAL I SPECTION. <br /> SIGNED '- .TITLE <br /> r <br /> RAW PLOT PLAN ON REVERSE SIDE) <br /> - . .w, ,-�-..FOR-DEPARTMENT USE-ONLY. . <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE /Q <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 12i <br /> 2M <br /> 0�7.7 <br /> E H 1426 Rev- 1-74 <br /> _ <br />