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- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOSrflFFTCE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMA' PERMIT' Permit No, �s .V-6�P <br /> THIS PERMIT WIRES 1 YEAR FROM DATE ISSUED Date issued <br /> (Complete In Triplicate) <br /> Application is Thereby 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 Regu do of the 'S n Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION '44-0 <br /> /'�g CENSUS TRACT <br /> Owner's Name Phone <br /> Phone ! �` <br /> Address <br /> City �L - <br /> Contractor'a .Na <br />{f License #-94&o& Phone fm <br /> i - <br /> TYPE OF WORK (Check): NEW WELL/? DEEPEN /-7 RECONDITION /7 DESTRUCTION _� <br /> AL <br /> I PUMP INSTLATION / / PUMP REPAIR /-7—PUMP REPLACEMENT <br /> f <br /> Otherj/ <br /> / / <br /> ` 11 <br /> DISTANCE TO NEAREST: SEPTIC,TANK SEWER LINES PIT PRIVY <br /> i SEWAGEODISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVA`T'E DOMESTIC WELLV— PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial i Cable Tool Dia. of Well Excavation <br /> Domestic/private i Drilled <br />! Dia, of Well Casing + <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation i Gravel Pack Depth of Grout Seal <br /> Cathodic Protection if Rotary Type of Grout <br /> Disposal i Other _ Other Information <br /> Geophysical. Surface Seal Installed BY: <br /> PUMP INSTALLATION. 1 <br /> Cantractar '� ✓�' '� <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: Er State Work Done <br /> PUMP'`-REPAIR: /? State Work Done <br /> E& RUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <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 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 put ting.. the..well in.use.. The above <br /> information is true. to the-beet of my knowledge and belief. I WILL CMX FOR A 'GROUT INSPECTION <br /> PRIOR TO GROTING AN FINALiINSPECTION. <br /> SIGNED <br /> TITLF;� 04� <br /> I (DRAW PLOT PLAN ON REVERSE SIDE <br /> � <br /> FOR—DEPARTMENTPHASE I USE ONLY <br /> APPLICATION ACCEPTED BY ” <br /> ADDITIONAL COMMENTS: DATE 7D� <br /> PHASE II GROUT INSPECTION PHASE 114 EINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYda DATE <br /> E H 1426. . Rev. 1-74 <br />