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r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0i OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;�j-Zj2 � : <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued O l7 7J <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_186 an the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB 9DXRE0SS4/L04rCATION ,t,. P s CENSUS TRACT <br /> Owner's Name V t�-L.e�'� <br /> Phone 3 69`~ 2-F,0-3 <br /> Address City <br /> Contractor's Name /viue- Yy 1 License Phone 6 j <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION f-1 DESTRUCTION /-7 <br /> PUMP INSTALLATION/ PUMP REPAIR/ / PUMP REPLACEMENT / <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES- PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USETYPE 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 /> 4--- 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: <br /> PUMP INSTALLATION: Contractor C <br /> / <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work DoneJ pj )wit di,4� <br /> �� r <br /> PUMP .REPAIR: / / State Work Done <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 District <br /> and. the State of California pertaining to or regulating well'const:ruction. 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 /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTIN : AND A FINAL INSPECTION. <br /> SIGNED - TITLE_ r I: <br /> !TKDRAW PL5T PLAN ON REVERSE SIDE) r <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY E DATE <br /> E H 1426 Rev. 1-74 <br /> 3/76 2M <br />