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SAN JOAQUIN LOCAL'.HEALTH DISTRICT <br /> FOROF ICE 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 /> (Complete- In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct f <br /> and/or :install thelwork herein described: This application~,is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and <br /> the Rules and -Regulations. of: the .San Joaquin Local Health District`. <br /> JOB ADDRESS/LOCATION o yrl4L��,�,Q,�t� �,� CENSUS TRACT � <br /> Owner's Name �� g ��" Phone <br /> ilw <br /> Address - �� -_ _C2 "_•• . . } / rf ------•----- City . <br /> Contractor's .Name bta �, _ License # t 'hone <br /> : <br /> TYPE OF WORK (Check): NEW WELL ,/-T DEEPEN -/? RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT 67 <br /> Other !/_7 <br /> r— ,I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY . <br /> SEWAGEIDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> J <br /> Industrial IA Cable Tool Dia. of Well Excavation <br /> Domestic/private i Drilled Dia. of Well Casing <br /> omestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary -Type of Grout j <br /> Disposal Other Other Information <br /> Geophysical Surface Seal. Installed By: <br /> PUMP INSTALLATION. Contractor <br /> Type sof Pump H.P. <br /> �jtate <br /> PUMP REPLACEMENT: / / Work Done <br /> k <br /> PUMP :REPAIR: /7 State Work Dane <br /> 4ESIRUCTION OF WELL: Well ,Diameter y �, Approximate Depth <br /> Describe Material and Procedure -w <br /> I hereby. ag3ree 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.knowle e •aiid lief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO- NG AND FINAL INSPE O <br /> SIGNED' TLE2 - <br /> Iz. PRAY PLOT PLAN ON REVERSE SIDE <br /> FOR D' TMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE J 6 <br /> ADDITIONAL COMMENTS: (� <br /> PHASE II GROUV INSPECTION PHASE II NAL INSPECTIO <br /> r INSPECTION BY , DATE INSPECTION. BY, -- DATE <br /> r <br />� � <br /> ' E <br /> H 1426 Rev. 1-74 .•w - � - ,Y .. -•� � 1-74 2M <br />