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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF,OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-67$1,x. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. z _/z 1'9� <br /> THIS PERMIT -EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> t (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 made in compliance with San Joaquir <br /> County Ordinance. No.,1862 avid the Rules d Regul t' ns of the <br /> VZn Local Health District, <br /> plot <br /> JOB ADDRESS/LOCAT ENSUS TRACT <br /> Owner's Name Pho <br /> 4t6,3771 <br /> ,�- <br /> Address Cit <br /> Contractors NameM License JV one 140 <br /> _ <br /> TYPE OF WORK (Check): NEW WELL '/�-/ y DEEPENI /Y RECONDITION I_ DESTRUCTION�/� <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <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 <br /> -T— <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS U <br /> i Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well' Casing v\S <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seall r <br /> Cathodic-Protection Rotary�a Type of Grout ' <br /> Disposal �- . ,. Other Other Information <br /> Geophysical ` ` Surface Seal Installed`E \ <br /> PUMP INSTALLATION:­� .1K. Contractor - s ti <br /> Type' of Pump .H.P. <br /> PUMP REPLACEMENT: / / State Work Dane <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 ''construttion. Within FIFTEEN PAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin. Local Health District i <br /> 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 and belief`: I WILL CALL FOR A GROUT INSPECTION` <br /> F PRIOR TO G OU NG AND A FINAL INSPECTIO 4. ^ <br /> SIGNED. %` TITLE ' <br /> (DRAW PLOT PLAN ON REVERSE SIDE ' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �2� DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPEC ION PHASE III/FINAL INSPECTION <br /> t INSPECTION BY DATE INSPECTION BY DATE <br /> F. H 1426 RPv_ 1-74 <br />