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SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOR 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 1 YEAR FROM DATE ISSUED Date Issued <br /> I (Complete In Triplicate) -(7 <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 /> G County Ordinance No. 1862 an#d the Rules and Regulations of the San Joaquin Local Health District. <br /> kj <br /> JOB ADDRESS/LOCATION Y o ss fib'u-L Q �� Irl G h CENSUS TRACT _ <br /> a <br /> ' Owner's Name 0 UPhone <br /> Address HST � „� 1�- Q_ City <br /> Contractor's Namee c +\Q'r h J License # <br /> i W L 8 Phone '9z,. <br /> TYPE OF WORK (Check): NEW WELL/ / DEEPEN -/_/ RECONDITION_/_� DESTRUCTION <br /> PUMP INSTALLATION/ / PUMP REPAIR-/—/ PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER` LINES PIT PRIVY <br /> SEWAGEDISPOSAL- FIELD . CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL '� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial I Cable Tool Dia. of Well Excavation <br /> Domestic/private I Drilled � <br /> Yy 3a_, of Well Casing W <br /> g . <br /> Domestic/public - " - -� i Driven Gauge of Casiii �- <br /> Irrigation -Gravel Pack Depth of Grout- Seal <br /> Cathodic Protection Rotary Type of Grout <br /> YP �. <br /> Disposal Other Other Information <br /> Geophysical. <br /> Surface Seal Installed- By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump - H.P. <br /> PUMP REPLACEMENT: <br /> / / State Work Done <br /> PUMP .REPAIR: ` <br /> /7 State Work. Done <br /> DESTRUCTION OF WELL: <br /> Well Diameter p.{� � pproxlipate Depth CD <br /> Describe Material and F/11 ocedure s <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 4 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..knoiwledge and belief, I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GAWTING ANDA .INSPECTION. <br /> SIGNED <br /> TITLEh <br /> I DRAW PI, T' PLAN ON RE�IERSE SIDE) ,I <br /> PHASE I t <br /> FOR DEPARTMENT USE ONLY <br /> , <br /> APPLICATION ACCEPTED BY ' <br /> DATES_-7?; <br /> ADDITIONAL COMMENTS: � <br /> PHASE II GROUT INSPECTION PHAS II/F AL INSPECTION f <br /> INSPECTION BY DATE INSPECTION BY DATE s ' <br /> �E H,.1426 Rev. 1-74 R 3/76 2 . <br />