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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOB;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 I YEAR FROM DATE ISSUED Date Issued 6- 7 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local11calth District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquinl <br /> County Ordinance No. 186;,,and the Rules and Regulations of the San Joaquin Local Health District, <br /> T47 /yj� <br /> JOB ADDxEss/x.ocATION an _. . y SUs TRACT <br /> Owner's Name ' <br /> Phone <br /> Address . <br /> City <br /> Contractor's Name License ` d , Phone LICL <br /> TYPE OF WORK (Check): NEW WELL '/7 DEEPS Lar RECONDITION /_7 DESTRUCTION f7 <br /> PUMP INSTALLATION '/ / PUMP REPAIR'/_7 PUMP REPLACEMENT /7 <br /> Other . <br /> DISTANCE TO NEAREST: SEPTIC TANK' r /SEWER LINES PIT PRIVY <br /> SEWAGE DISPO AI, FIELD CESSPOOL/SEEPAGE PIT OTHER • <br /> PROPERTY LINE -PRIVATE ES <br /> DOMTIC WELL- PUBLIC DOMES <br /> INTENDED. USE TYPE OF WELL CONSTRUCTION SP S <br /> Industrial ` Cable Tool Dia. 'of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public ' Driven Gauge of Casing <br /> Irrigation _ Gravel Pack . Depth of Grout Seal <br /> Cathodic Protection Rotary Type ,of Groat <br /> Disposal OtherA Other Information ; <br /> Geophysical /=/-,�/:D . Surface Seal Installed 'B <br /> PUMP INSTALLATION: C Otractor `tom <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: E7 Staie-Work Done <br /> PUMP REPAIR':—** " .` /7 State-Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth , <br /> Describe Material and Procedure i <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 INSPF,4110N <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED � TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID i <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE6 _7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P.HM4I AL INSPECTIO <br /> INSPECTION BY DATE INSPECTION Byey, <br /> Z, DATE <br /> E H 1426 IZA%r- 1_74 ► �..r <br />