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r'Ca SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORrOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone:- (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. n/—X 8 ,P <br /> r <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued z y,z <br /> ., (Complete In Triplicate) <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 a►ade in compliance with San Joaquin <br /> Coin S3rdinanee_No.. 862. and .the Rules and Regulations of the San Joaquin Local Health District. <br /> . . <br /> JOB ADDRESS/LOCATION <3 w r �0 d� CENSUS TRACT <br /> ��� <br /> Owner's Name (§-0 a L Phone / <br /> Address City �1 G <br /> Contractor's Name License #/.�� j---hone <br /> i <br /> I <br /> TYPE OF WORK (Check): NEW WELL/ / DEEPEN '/ RECONDITION /-7 DESTRUCTION /"7 <br /> PUMP INSTALLATION / / PUMP REPAIR L)� PUMP REPLACEMENT /? <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY o <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGR. PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL.' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private ;Drilled Dia. of Well Casing <br /> Domestic/public" Driven Gauge of Casing <br /> ---�C Irrigation Gravel Pack Depth of Grout Seal <br /> ' Cathodic Protection Rotary Type of Grout , <br /> Disposal ' ' . Other tither Information <br />' Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ' <br /> Type of Pump ��✓ .,. H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: State Work Done - 6c� _o r <br /> ,DES'ERUCTION 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 notify them before putting-the-well in.use. The above <br /> F information is true to the-best-of my knowledge and belief. I WILL CALL FOR A'GROUT, INSPECTION <br /> PRIOR TO ftE2UING AND A FINAL INSPECT N. <br /> SIGNED -. TLE <br /> (D PLO TTAN ON PJ RSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE.I 7 <br /> APPLICATION ACCEPTED BYIL;24DATE <br /> ADDITIONAL COMMENTS: Ole <br /> PHASE II GROUT INSPECTION PHASE, II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION. DATE 6 <br /> E H 1426 Rev. 1-74 ' 1-74 2M <br />