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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOL OFFICE USES 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 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. F <br /> JOB ADDRESS/LOCATION 0 0<? - � 1Q f 0F�NSUS TRACT <br /> "' <br /> Owners Name <br /> Address <br /> ` f City ' <br /> r License # 4 �1 j Phone <br /> Contractor's Name <br /> `i <br /> TYPE OF WORK (Check) : NEW WELL /Tfv' DEEPENI_I RECONDITION / DESTRUCTION /_ <br /> AL <br /> PUMP INSTLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK /Q�0_1 SEWER LINES _ PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER S� Ead <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL 2 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONSi \ <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation _ / Gravel Pack Depth of Grout Seal q <br /> ► _ <br /> Cathodic_Protection - <br /> " <br /> Disposal - Other Other Information ? <br /> Geophysical ¢' Surface Seal Installed B r ^- <br /> �' 14M n DSS„/?a� ` "69M rT y OW rJ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump _?'4t4. -� .� H.P. /-o <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PU� P .REPAIR: _ / / State Work Done <br /> IES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I''iereby 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 G UTING ,AND A, AL INSP 101, <br /> S NED 'a4 rz). TITLE d , <br /> "M­rW I` PLAN ON RE LRSE SIDE i <br /> -camas L FO EPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: ” <br /> 11 PHASE I GROUT INSPECTION PHASE /FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY�/ DATE <br /> !it�ad' <br /> H 1426 Rev. 1--74 �� /,/ 'r 0, <br />