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,_ �[�SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS: OFFICE USE: 1601 E. Hazelton Ave. , •Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2,7-,5-,-1 � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issuedj7 <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 CENSUS TRACT <br /> Owner's Name Phone J U' 1 <br /> , Address City ��0 <br /> Contractor's Name - —.License # Phone <br /> TYPE OF WORK (Check) : NEW WELLDEEPEN /% RECONDITION /—/ DESTRUCTION /-7' <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT -7 oQ <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> Al <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED- USF T" ._ J - TYPE OF WELL CONSTRUCTION SPECIFICATIONS 3 <br /> Industrial Cable Tool Dia. of Well Excavation 12 <br /> Domestic/private "7�- Drilled Dia, of Well Casing / 2 <br /> -�- Domestic/public Driven Gauge of Casing <br /> 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 /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DES-i 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 of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTD G & A F A INSPECTION. <br /> SIGNED A A TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) ct�r <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYDATE 6 , <br /> ADDITIONAL COMMENTS: <br /> PHASE II' GROUT INSPECTION PHASE I I/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 1177 . #2M <br />--`- E H 1426 _ Rev. 1-74 _ �_;� <br />