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/ T e-M4IC <br /> FOROFFICE Fig/�iiT To <br /> d SAN JOAQUIN�LOCA16 HEALTH DISTRICT <br /> USE; 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. lip-13,5/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued,5 -13-7Y <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 a t is made in compliance with San Joaquin. <br /> County Ordinance No. 1862 and the Rules and' Reg� ofl the aJoaquin Local, health District. <br /> JOB ADDRESS/ OCATION ` US TRACT <br /> Owner s Namc Phone <br /> Address Address <br /> City -11-411 <br /> Contractor's Name <br /> ,� License # qp� y Phone <br /> + 15 <br /> TYPE OF WORK (Check) : NEW WELL / -DEEPEN r 4 - _ <br /> _/ / RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT— <br /> Other <br /> EPLACEMENTOther / / °a <br /> DISTANCE TO NEAREST: SEPTIC TANKt� SEWER~LIIVES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD f CESSPOOL/SEEPAGE 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 /> �V Domestic/private Drilled" Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing I <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection �� Other <br /> Type of gout <br /> Disposal Others Other Information <br /> _ p` <br /> Geophysical Surface Seal Installed By:---J , <br /> ` <br /> PUMP INSTALLATION: Contractor *.. <br /> Type of Pump '.� . H.P. , l" <br /> PUMP REPLACEMENT: / / State Work Done <br /> - <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 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 PR0jJTING AND A NAL INSPECTION. <br /> SIGNEDJ. <br /> TITLE <br /> ( W PL PLAN 0EVERSE SIDE) , <br /> FOR DEPARTMMiT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �� DATE ^ <br /> ADDITIONAL COMMENTS: <br /> PHASE V G OUT4 INSPECTION PHASE I FINAL INSPECTION <br /> INSPECTION BY ATE Z-7 7 g INSPECTION BY DAT - -7f--' <br /> 4 ��... .� A?!H 1426 Re742M�� { <br />