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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOReOFFICE USE: f 1601. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PULP PERMIT Permit No.,� VYa,�) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ` <br /> (Complete In Triplicate) 7� <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 made in compliance with San Joaquin <br /> County Ordinance No. . 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> kle <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address zw, 3,Pjr <br /> City /. <br /> Contractor's Name License # Phoneme <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN '/-7 RECONDITION /-7 DESTRUCTION f7 <br /> PUMP INSTALLATION PUMP REPAIR /% PUMP REPLACEMENT 1-7 <br /> Other /-7 <br /> — <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 G1 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation f �j <br /> _ 9 Domestic/private Drilled Dia. of Well Casing 1 <br /> Domestic/public Driven Gauge of Casing p <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 f-1 State Work Done <br /> PUMP 'REPAIR: /7 State Work Done <br /> ES;i UCTION 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 alth District a <br /> WELL DRILLERS REPORT of the well and notify them before putting..the- wellse.. The above <br /> information is true to the-best of my knowledge and belief. I W!;k=gAakg2B=L4R49UT-1-N,5PZMON <br /> PRIOR TO GROUTING A FINAL,IMECT ION. <br /> SIGNED TITLE <br /> RAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I q G� <br /> APPLICATION ACCEPTED BY DATE / 2 <br /> ADDITIONAL COMMENTS: f <br /> PHASE II GROUT INSPECTION PHA§Y� III4 <br /> SPINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE �? <br /> 0 E R 1426 Rev. 1-74 <br /> 1-74 2M <br />