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SAN JOAQUIN LOCAL .HEALTH DISTRICT - - <br /> FOR•e'OFFICE USE: 601 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 2ATE. ISSUED Date Issued t <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 ,- fa- CENSUS TRACT <br /> Owner's Wamie M 15-- P6 Phone <br /> Address City �Sc-i3kokl <br /> Contractor's Name <br /> �J License # ,� Phone <br /> TYPE OF WORK (Check): NEW'WELL /7 DEEPEN /-7 RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <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 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing Ira <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 B <br /> PUMP INSTALLATION: Contractor ; , &)17-0Al <br /> Type of Pump �i v - H.P. l <br /> PUMP REPLACEMENT: / / State Work Done t <br /> PM".-REPAIR: /-T -State Work Done - - I <br /> r <br /> &TRUCTION 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 regulat.ing.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 GRO TING AND FINAL INSPECTION. <br /> SIGNED TITLE k <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FWPEPARTME9T USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTEDlkly i/V O DATE - 2.3" <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS III F AL INSPECTION <br /> INSPECTION BY DATE---, INSPECTION BYAE , DATE ' <br /> �m <br /> g �; el--- <br /> t <br /> 1 E H 1426 Rev. 1--74 -T, .,.. <br />