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SAN JOAQUIN LOCATE BEALTH DISTRICT <br />, FOWrOFFICE USE, 1601 E. Hazelton Ave. , Stockton, Calif. 7 <br /> I 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 -�- -7 <br /> (Complete In Triplicate) <br /> Application is hereby made toIthe San Joaquin: Local Health District for a permit to construct x <br /> and/or install the work herein described. This application is made in compliance with San Joaquin: <br /> County Ordinance No. 1862 �n'd�the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION / �(Z S CENSUS TRACT <br /> Owner's Name Y!/ Phone <br /> 7/ , <br /> Address City / 1,/ ! <br /> 1+ License 1f 2 SJ 777 Phone !a�J 4`9 M <br /> Contractor's Name <br /> 'YPE OF WORK (Check}: NEWjWELL DEEPEN -7 RECONDITION /_7 DESTRUCTION ( 7 <br /> PUMP INSTALLATION. /Pf PUMP REPAIR / / PUMP REPLACEMENT <br /> ' Other <br /> f <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ PIT PRIVY> <br /> SEWAGE -DISPOSAL, FIELD CESSPOOL/SEEP,AGE';PIT OTHER <br /> PROPERTY LINE/09-PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> x IO, Q <br /> Industrial i Cable Tool Dia. of Well Excavation <br /> t---Domestic/private Drilled Dia. of Well Casing ' <br /> of Casin <br /> Gauge <br /> Domestic/public i DrivenE � <br /> Irrigation I Gravel Pack Depth of Grout Seal D <br /> Cathodic Protection V Rotary Type of Grout ✓y <br /> Disposal Other Other Information <br /> Geophysical !: Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump Z 7- ,Sr H.P. <br /> { <br /> PUMP REPLACEMENT: / / State Work Done '- <br /> PUM .REPAIR: /_7 State Work Done - <br /> Approximate Depth <br /> i ,pES�RUCTION OF WELL__: Well Diameter pp , <br /> i Describe Material and Procedure <br /> 4 i�, <br /> f 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 /> i 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 AND A NAL fSPECTION. <br /> SIGNED 4 TITLE <br /> 1 (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY q <br /> PHASE� I DATE / 3 <br /> APPLICATION ACCEPTED BY <br /> 12 <br /> ADDITIONAL COMMENTS: . s <br /> P E II ROUT INSPECTION PHAS III FIN INSPECTION <br /> s INSPECTION BY DATE f - INSPECTION BY DATE <br /> 1-74 2M <br /> 1t E H 1426 Rev. 1-74 - <br />