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FOR 'OFFICE USE: DISTRICT <br /> SAN JOAQUIN LOCAL HEALTH - - �--- <br /> li 1601 E. Hazelton Ave. , Stockton, Calif. { <br /> ii Telephone: (209) 466-6781 �. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 35[ <br /> fpa <br /> i� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' Date Issued <br /> it (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> axed/or install the work ' described. This application is -made in compliance with San Joaquin' <br /> County Ordinance No. 1862 and the Rulesd Regulations of rhe San Joaquin Local Health District. <br /> JOB ADDRESS/LION. / CENSUS TRACT <br /> I� 1 <br /> Owner's Name <br /> PhoneC?J ;�)L <br /> :Address <br /> Cit a <br /> Contractor's Nam .Z= !/ License <br /> �h <br /> li <br /> TYPE OF -WORK (Check): NEPi.W WELL/-7 DEEPEN '/7 RECONDITION DESTRUCTION /7 <br /> OtUMP <br /> P INSTALLATION <br /> ST LATION �/ PUMP REPAIR /_7 PUMP REPLACEMENT � `� + <br /> !ii W <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY _ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER a`F` . <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL: PUBLIC DOMESTIC WELL" <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICAT S <br /> Industrial 7 cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic i <br /> /public Driven Gauge of Casing . <br /> Irrigation —.,Gravel Pack Depth of Grout Seal � <br /> Cathodic Protection Rotary Type of Grout <br /> Dispy <br /> Geosi r OtheOther Information ; <br /> Geophhysical Surf a .Se` Installed 15 : <br /> PUMP INSTALLATION: Can actor V110 � � �, � • <br /> ` Type of Pump H.P. <br /> f . i <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP"'REPAIR: Y " State`Work-Don -, _ .� <br /> ---- <br /> ES'TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to complywith all laws and regulations of the San Joaquin Local Health District i <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..weli 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 FINAL INSPECTION. <br /> SIGNED TITLE <br /> ii DRAW PLOT PLAN ON REVERSE SIDE <br /> � �� " <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY yr <br /> ADDITIONAL COMMENTS: <br /> -� DATE —7� <br /> , _... <br /> * PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY , DATE INSPECTION BY DATE Z-'Z <br /> E H 1426 Rev. 1-74 <br /> 1-74 2M t <br />