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} , f 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 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> _c_7 ,�'� o;-£ l,4 (Complete In Triplicate) <br /> z App i'cat�on is hereby made to the San Joaquin Local Health District fora permit to <br /> and/or install the worm herein described, p construct <br /> This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ] `` , <br /> .10 (;)� LCENSUS TRACT <br /> Owner's Name ` <br /> Phone <br /> Address <br /> u City <br /> Contractor's Name, ' fi <br /> License # Phone <br /> 'S i <br />-TYPE_OF WORK--(.Check)_:—NEWpWELL,/�EEPENi/ 1--RECONDITION /�-/ DEST'RUCTION� <br /> PUMP INSTALLATION / / PUMP REPAIR /? T <br /> Other / / I.I PUMP REPLACEMENT /� - <br /> DISTANCE TO NEAREST: SEPTIC TANK i�j U 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 A` <br /> Industrial Cable Tool Dia. of Well Excavation # <br /> Domestic/private Drilled Dia. of Well Casing <br /> D este/public - _.. <br /> Driven g <br /> - Gauge of Casing <br /> Irrigation � ,. „ <br /> ;Gravel Pack Depth"bf Grout eal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: ' / / State Work Done <br />.PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION 0P'WELL; 4" Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> c <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 notifythem before <br /> 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 INSPECTIOIV <br /> PRIOR TO- GROUTING AND A FINAL INSPECTION. <br /> l <br /> SIGNED `y TITLE <br /> DRAW ' T PLAN 'ON' REVERSE SIDE <br /> PHASE,I F DEPARTMENT USE ONLY <br /> APPLICATIONiACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE 7 Z2/! <br /> PHASE II: GROUT INSPECTION PHASE'?IIZ/FINAL INSPECTI N <br /> INSPECTION-,BY DATE _ INSPECTION BY f/ DATE <br /> E H 1426 Rev. 1-74 /A <br /> IPIOSVO ".. r� - s.�• 3/76 2M <br />