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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> _TOAOFFICE OFFICE USE: /1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. F-s-4J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued.- /x_O5_ <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-i . 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 /> Otmer p s Name Phone -- <br /> Address av �..) . � Cit y _�..,._.. <br /> Contractor's Name License #.aW ?1eftone <br /> TYPE OF WORK (Check): NEW WELL /5< DEEPEN / RECONDITION /_7 DESTRUCTION F7 <br /> PUMP INSTALLATION b? PUMP REPAIR / / PUMP REPLACEMENT <br /> Other /J <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PI-T2 <br /> y I OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC OMESTIC WELL <br /> INTENDEDS <br /> U E 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 /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection _< Rotary Type of Grout r► =r -or � <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump v �r r�' H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP'.REPAIR: /7 State Work Done d <br /> ES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply uiitti al3"-Tata8 <br /> 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 a well and notify them before putting the well in -use.. The above <br /> information is ru o the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUT tN P <br /> SIGNED TITLE r. <br /> f (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE vh� <br /> S <br /> APPLICATION ACCEPTED BY cc <br /> ,. <br /> ADDITIONAL COMMENTS: - <br /> PHASE/Q11/GROUT INSPECTION PHASE FINAL INSPECTION / <br /> INSPECTION BY D TE S INSPECTION BY DATE <br /> ' <br /> 8 H 1426 Rev. 1-74 1-74 2M <br />