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r SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE iCE USE: 1601 E., Hazelton Ave. , Stockton, Calif. <br /> `I Telephone: x(209) 466-6781 <br /> APPLICATION FOR WELL, 'CONSTRUCTION OR PUMP PERMIT Permit No. z-z?a yo ; <br /> _ - <br /> le . <br /> THIS PERMIT EXPIRES 1- YEAR FROM DATE-ISSUED Date Issued <br /> :>(Complete In Triplicate) <br /> Application is hereby made toIthe San Joaquin Local HealthYDi,stirict 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.'-186.2- anc31the Rul and :Regulations of the. San Joaquin Local Health District. <br /> JOB ADDRESS/LOCAT r} CENSUS TRACT <br /> Owner°s Name (r -�- Phone%lz <br /> r C�3 <br /> Address . ; _ Ci -�� <br /> Contractor's NameLicense. #/Vl J �( � <br /> Phan <br /> TYPE OF WORK (Check) : NEW WELL /-7 DEEPEN -/-7 RECONDITION /-7 DESTRUCTION /_ <br /> PUMP :INSTALLATION / / PUMP REPAIR /_7 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 45J � <br /> Industrial Cable Tool Dia. of Well Excavations <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 Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: _..,.......,_� <br /> PUMP INSTALLATION: Contractor <br /> Type of .Pump H.P. <br /> PUMP REPLACEMENT: State Work 1 <br /> PUMP iREPAiR:-. _. - .—/7—State-Work-Dong � - -=-- <br /> PE&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 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 DRILLER_ PORT of -he well and notify them before putting-thewell in-use.. The above <br /> informati is t ue to e e t-of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> FRIOR TO R I G D INSPECTION. <br /> SIGNED TITLE, <br /> i. (DRAW PLOT PLAN ON REVERSE SIDE <br /> 1 <br /> CHASE I FOR DEPARTMENT USE ONLY E <br /> APPLICATION ACCEPTED BY . DATE <br /> ADDITIONAL COMMENTS: 1. L z , <br /> PHASE II GROUT INSPECTION ----PWAag II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> i, E H 1426 Rev. 1-74 1-74 2M <br />