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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ' Fd$.OFFICE USE: I� 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> 11 (Complete In Triplicate) <br /> Application is Aereby madelto the San Joaquin Local Health District for a permit toconstruct <br /> and/or install the work herein described. This application is made in compliance with San Joaquil <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> 1 . <br /> JOB ADDRESS/LOCATION 7,r eCENSUS TRAGI <br /> { <br /> 04ner's Name _ Phone <br /> Address ; � city <br /> Contractor's .dame S p�� License # 12 0 e)Phone. - . n -� <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN /7 RECONDITION /7. DESTRUCTION /_7 <br /> PUMP INSTALLATION ./—] . PUMP REPAIR / / PUMP REPLACEMENT ` <br /> Other Z77 <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 6 <br /> INTENDED USE XY'PE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial t 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 :i Rotary Type of Grout <br /> —Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: &/Z <br /> / State Work Done �� f - Z <br /> , f <br /> PUMP .REPAIR: i <br /> / / State Work Dane <br /> ` DESTRUCTION OF WELL: Well .Diameter Approximate Depth <br /> Describe Material and Procedure <br /> II hereby agree to comply with all lavas and regulations of the San Joaquin Local Health istiict <br /> t 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 e <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 /> EPRIOR TO OU ING .AND FINAL INSPECTION. <br /> SIGNED TITLE <br /> ' (DRAW PLOT PLAN ON REVERSE SIDE <br /> k FOR DEPARTMENT USE ONLY <br /> i PHASE I <br /> ' APPLICATION ACCEPTED BY r DATE 'J- P—? , <br /> ~ ADDITIONAL COMMENTS: 1 <br /> PHASE. II GROUT INSPECTION P $ I F AL INSPE <br /> INSPECTION BY DATE /!/ INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 11177 2M � <br />