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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFF-;CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. j <br /> Telephone (209) 466--678 . <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED. Date Issued 9—IS:27 <br /> # (Complete In Triplicate) i <br /> Application is hereby made to the San Joaquin Local Health District fora 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 { CENSUS TRACT <br /> Owner's Name - - Phone <br /> R <br />' Address City <br /> Contractor's NameLicense J hone � 2d/ <br /> i <br /> i� <br />,. TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION / / DESTRUCTION <br /> i PUMP INSTALLATION ,/ / PUMP REPAIR / / PUMP REPLACEMEN <br /> Other'L / JO <br />. DISTANCE TO NEAREST: SEPTIC :TANK SIrWER .LINES PIT- P-R-IVY <br /> SEWAGE'}DISPOSAL FIELD CES OOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC .DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �• <br /> Industrial :6. Cable Tool Dia, of Well Excavation <br /> Domestic/private ! Drilled Dia. of Well Casing <br /> Domestic/public I Driven Gauge of Casing <br /> Irrigation Gravel Pack, Depth of Grout Seal <br /> Cathodic Protection ;I Rotary 'Type of Grout � <br /> Disposal Other Other Information <br /> Geophysical. Surface Seal. Installed B : <br /> PUMP INSTALLATION. Contractor <br /> Type of Pum H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br />''. PUMP .REPAIR: State Work Done <br /> DESTRUCTION 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 DRILLERS REPORT of the well and,n'otify them before putting the well in use. The above <br /> information is true to the best 0,4, my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING FINAL `'N <br /> SIGNED AQV z 11w TITLE <br /> r � {DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE. ONLY <br /> PHASE I <br /> APPLICATION AG(;ErTED'<EY >�f��` ��1,.,.u_ k� DATE <br /> ADDITIONAL -COMMENTS: <br /> PHASE .II.: GROUT}:INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION 'DATE INSPECTION BY DATE <br /> E H 1426 -Rev.'-,1-74 <br />