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G c m. } C SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORIOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> , ,.. <br /> Telephone. (209) 466'-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. TS-lv d{o <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,2T,S' <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,iwork hereii► described. This application is made in compliance with San Joaquin <br /> County Ordinance 'No.. 1862 andlthe Rules and -gulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION /'%' 4 CENSUS TRACT <br /> G <br /> Owner's Name --.i':y Phone <br /> ^" <br /> Address Z9 �'�. f� , F �► City .� <br /> Contractor's Name <br /> License # �%L-7lone to <br /> TYPE OF WORK (Check): NEW WELL I DEEPEN RECONDITION /-7 DESTRUCTION f7 <br /> PUMP INSTALLATION / / PUMP REPAIR ./ / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTICTANK 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 <br /> Industrial i Cable Tool Dia. of Well Excavation <br /> Domestic/private i. Drilled Dia. of Well Casing Zi <br /> Domestic/public t Driver: Gauge of Casing <br /> Irrigation _i Gravel Pack Depth of Grout Seal <br /> Cathodic Protection '! Rotary Type of Grout <br /> Disposal .t Other Other Information �° <br /> Geophysical Surface Seal Installed By: <br /> �^ <br /> r � <br /> PUMP INSTALLATION: Contractor H.P. / <br /> Type of Pump <br /> PUMP REPLACEMENT: / ./ State Work Done <br /> PUMP .REPAIR: State Work Done ble l s�e, <br /> Approximate SES TRUCTION flF_WELL: Well ;Diameter A pp Depth <br /> Desc ,he 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 /> l' WELL DRILLERS REPORT of the -well and notify them before putting.the..well in use.. The above <br /> I information is true to the•best-of my knowledge an b ief. I WILL CALL FOR A 'GROUT INSPECTION <br />{{{{ PRIOR TO TING AND A FINAL INSPECTI <br /> SIGNED TLE <br /> (DRAW PL2L PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: _ <br /> PHASE II-GROUT-INSPECTION PHASEIII FINAL INSPECTI9JU <br /> INSPECTION BY DATE INSPECTION- BY 0.,ezDATE /? <br /> 1-74 2M <br /> 'AE S 1426 Rev. 1.-74 � -_ <br />