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• j <br /> SAN JOAQUIR LOCAL HEALTH DISTRICT F <br /> FOk OFFICE USE: 1601 E. Hazelton Ave. ,. Stockton, Calif. <br /> s Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 7" Lv f <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date IssuedJ , J <br /> - A (Complete In Triplicate) � <br /> Application is hereby made tol.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 and1,the Rules and gulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION � r� <br /> -C-l�2U CENSUS TRACT ' <br /> Z274 4d c - <br /> Owner's Name Phone �~� <br /> Address C[.LIQ City <br /> / �� o ' <br /> Contractor's e � LicensePhone <br /> �' _ �/� <br /> 4 <br /> TYPE OF WORK (Check) : NEW WELL AL/ / DEEPEN%/ RECONDITION / / DESTRUCTION /� { <br /> PUMP INSTLATION / / PUMP REPAIR / / PUMP REPLACEMENT 2 <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 USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS _ <br /> Industrial I Cable Tool Dia. of Well. Excavation <br /> Domestic/private !i Drilled Dia. of Well Casing <br /> Domestic/public A Driven Gauge of Casing <br /> Irrigation FI Gravel Pack Depth of Grout,-Seal <br /> Cathodic Protection 11 Rotary Type of Grout`s <br /> Disposal t Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ' H.P. ��- -- <br /> 4 <br /> PUMP REPLACEMENT: / / State- Work DoneeZ <br /> ` ` <br /> PUMP PREPAZR: `// 'State Work_Done" <br /> DESTRUCTION OF WELL:T 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 construction. Within FIFTEEN DAYS <br /> E 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 TOG UTING AN AL' !NSPFCTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> E FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> r <br /> APPLICATION ACCEPTED BY DATE ��—�� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIONPHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY &p DATE ' <br /> f o�77 2M <br /> i `-E H 1426 Rev. - l-74 = - <br />