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SAN JOA4 UIN LOCAL HEALTH DISTRICT <br /> FOE-OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. ,SC�41V'�V�4 <br /> Telephone: (209) 466-6781 r/ <br /> uvw APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> r ��� 1 � THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued G <br /> Application is (Complete In Triplicate) <br /> PP tereby 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 an the Rules and Regulations of the San Joaquin Local Health- District. <br /> �s(o � <br /> JOB ADDRESS/LOCATION �� CENSUS TRACT <br /> 1 <br /> Owner's Name O �- 1 i W" '�` Phone ef, S/E / Q <br /> Address /11 (��-` �� �� l� �0 Cit /-•-- f <br /> Contractor's Nam <br /> ijv �f' License /��hone 2 <1,5-I3 � <br /> i <br /> TYPE OF WORK (Check) : NEW WELL /^ DEEPEN / / RECONDITION / / DESTRUCTION /_7 �- <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-J <br /> Other /% <br /> DISTANCE TO NEAREST: SEPTIC TANKQ 4=�to SEWER LINEM PIT i-RiVY <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 /> Q - _ <br /> ! ---D `mestic/private Drilled Dia. of Well Casings <br /> Domestic/public Driven Gauge of Casing Z 0 _ <br /> Irrigation Gravel. Pack Depth of Grout Seal a G <br /> Cathodic Protection otary Type of Grout m <-- <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor rt c:,m. <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,,REPAIR: / / State Work Done "1 <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 bistrict <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 1 <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECT ON. <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> STGNED Z, TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY A <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 1 <br /> 7 ' <br />_ _ E H 1426 Rev. 1-74 � i f. .] `, ,. � .:-� <br />