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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. zS1�4 <br /> THIS PERMIT EXPIRES 1 YEAR. PROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application 3.s 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 /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION lyjo� e f CENSUS TRACT <br /> Owner's Name Phone �� <br /> Address City C <br /> Contractor's Name License # 1f Phone 9!j;P' aS70 <br /> TYPE OF WORK (Check): NEW WELL DEEPEN/_7 RECONDITION /-' DESTRUCTION f-T <br /> PUMP INSTALLATION / f PUMP REPAIR / f, PUMP REPLACEMENT %7 <br /> Other ] / <br /> DISTANCE TO NEAREST: SEPTIC TANK-.. SEWER LT ES PIT PRIVY <br /> SEWAGE DISPOSAZ�F D SS OOL SEEPA E T \ OTHER <br /> ROPE TY LINE .. STIC WELL <br /> INTENDED USE TYPE WELL CONSTRUCTION SPEC-r-FICATTONS— ?A <br /> Industrial _ Cable Tool Dia, of Well Excavation. <br /> Domestic/private Drilled Dia. of Well Casing ! f _mac <br /> Domestic/public Driven _Gaugeof_ Casing �11� jag <br /> Irrigations _ -, Gravel Pack Depth of Grout Seal <br /> Cathodic-Protection--- -Rotary ° _} -- --Type-of Grout. <br /> Disposal Other . - Other Information <br /> Geophysical 'Surf ace Seal Installed B : <br /> i SsL PA U/X wcz; <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 'H:P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: . >, /7 State Work Done' ' - — - - - <br /> &ES—T.RUCTION 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.J aquin 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 /> 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 /> DRAW PLOT PLAN ON REVERSE SIDE <br /> 112 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �` [y <br /> APPLICATION ACCEPTED BY DATE 7 `J ;�s <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE T kI AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY _ DATE J� <br /> ! E H 1426 : Rev. 1-74. 1-74 2M <br />