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g SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF�rOFFICE 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 la jL <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District t fo r a permit to construct <br /> and/or install the work herein described. This application is :Wade in compliance with San Joaquin <br /> County Ordinance Na. 18 2 d the Rules and Regulations of the San 3oaquin Local Health District. <br /> f <br /> JOB ADDRESS/LOCATION _ CENSUS TRACT <br /> Owner's Name Phone q3 <br /> Address _ C� d `7 City <br /> Contractor's Name License # L 4 Phone 53'97 } <br /> TYPE OF WORK (Check): NEW WELL 17 DEEPEN /7 RECONDITION /_7 DESTRUCTION / <br /> PUMP INSTALLATION / / PUMP REPAIR /-7-PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER-LINES PIT PRIVY <br /> SEWAGE ,DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER i <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> IN'CENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/Private Drilled Dia. of Well Casing Q <br /> Domestic/public Driven Gauge of Casing Lz <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 INS9CALLATION: Contractor <br /> Type of Pump H.P. <br /> k <br /> PUMP REPLACEMENT: f:7 State Work Done <br /> PUMP 'REPAIR: "" J? , ,.. J S•t --. _,,:,: <br /> S•TRUCTION OF WELL: Well Diameter ��� 9.3� <br /> �E—�---.• 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 GROUTING �iD A' F AL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY . <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL, COMMENTS: <br /> P E ROUT INSPECTION P E I INAL INSPECTI N <br /> INSPECTION BY DATE -a-� INSPECTION B DATE 7 <br /> l ^E H 1426 Rev. 1-74 1-74 2M <br />