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E <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton :Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _3 _?V <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED .Date Issued <br /> ' I (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaqul <br /> County Ordinance No. 1862 rind t e Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION A <br /> 4LZCENSUS TRACT <br /> Owner's Name Phone <br /> f Address f '& <br /> City <br /> Contractor's Name License # Jl 674 Phone , <br /> TYPE-OF.WORK (Check): NEW WELL /? DEEPEN -/,ff ' RECONDITION /_f DESTRUCTION /7 <br /> PUMPJINSTALLATION / / PUMP REPAIR '/� PUMP REPLACEMENT j T <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK d SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD ES-SPOOL/SEEPAGE"PIT OTHER-,." <br /> PROPERTY LINE.-- PRIVATESTIC _ ELL_ ..._EUBLIC DOMESTIC WE {: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS*- . <br /> Industrial Cable Tool .� Dia: of Well Excavation R <br /> _ Ao stic/private Drilled ;.- Dia:- cif.-Wel,l Caning �r <br /> t <br /> Domestic/public Driven *Gauge of Casing <br /> /.-,ItL d�11 <br /> IrrigationGravel Pack— Depth of Grout. Seal <br /> Cathodic Protection Rotary , , Type of. Grout w ,, <br /> �. Disposal 3 Other Other Informatibn is <br /> Geophysical �Surf:aceSesl Installed B <br /> y <br /> PUMP INSTALLATION: Contractor <br /> + Type'of Pump- - <br /> PUMP REPLACEMENT: � / / -State Work Done <br /> PUMP-.REPAIR: / / State Work Done s x <br /> DESTRUCTION OF WELL: Well Diameter ' Approximate Depth" :41 <br /> Describe Material and Procedure N, <br /> 10 <br /> I hereby,. agree-to comply with. all•-laws and regulations--of''the -San -,Joaquiri'Local-Hda-Tth--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 .° <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. <br /> + SIGNED <br /> TITLE ;f ' <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> 4 ADDITIONAL COMMENTS: / <br /> PHASE II PECTION ' PHA I INAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY -DATE <br /> E H 1426 Rev. 1-74 rr' 4 11/7t 9M <br />