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I ' SAN JOA UIN LOCAL REALTH DISTRICT - - <br /> FORrO , BICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. 1 <br /> Telephone:,_ (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No...... <br /> i <br /> THIS PERMIT EXPIRES l YEAR FROM DATE& ISSUED Date Issued .6 <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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. � <br /> JOB ADDRESS/LOCATION / ►` v, �j e►�lA o► CENSUS TRACT <br /> s <br /> a <br /> Owner's Name �. G,• Phone <br /> Address !.J i. City <br /> Contractor's Name License #l y3 2_.,_'f4one 1162, <br /> 7 <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN j-7 RECONDITION /_7 DESTRUCTION <br /> AL <br /> PUMP INSTLATION REPAIR j_/ PUMP REPLACEMENT <br /> Other IX! .. 0.01/ o .t <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT _ OTHER w <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation C <br /> _ Domestic/private Drilled Dia, of Well Casing (tj <br /> Domestic/public Driven Gauge of Casing <br /> ` 3C ---- 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 /> �.1 <br /> PUMP INSTALLATION: Contractor <br /> f ' <br /> Type of Pump H.P. S� <br /> PUMP REPLACEMENT: / / State Work Done �^ <br /> r .REPAIR:. / _State Work Done f_ , =yt �r1�_._ <br /> PES�RUCTION 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 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 putting. the .well in use.. The above <br /> information is true to the best y. ledge add belief. I WILL CALL FOR A GROUT INS ECTION <br /> PRIOR T'0 R TING D F S 0 <br /> SIGNED �Ci FILE Q:Ac <br /> (DTAW PtOT PLAN ON RE7ERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I s / OF <br /> APPLICATION ACCEPTED BY �� DATE '5 2-7X <br /> ADDITIONAL COMMENTS: ° <br /> PHASE II GROUT INSPECTION PHASE I £FINAL INSPECTION <br /> INSPECTION Bi DATE INSPECTION BY DATE <br /> TL <br /> ' `t „E H 1426 Rev. .1-74 1-74 2M <br />