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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: ' 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> 4 ,' Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued k--JZ--1.? <br /> i (Complete In Triplicate) <br /> Application is'Aereby made to the San Joaquin LocalHealthDistrict 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 /> JOB ADDRESS/LOCATION - CENSUS TRACT <br /> Owner's Name1&42 1 <br /> Phone~;2, 9 <br /> Address <br /> City <br /> Contractor's Name .License 11,1 /�hone <br /> TYPE OF WORK (Check) : NEW WELL /7 DEEPEN/_� RECONDITION /7 DESTRUCTION /—T <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT— <br /> Other / / <br /> t <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> " SEWAGE DISPOSAI, FIELD• t 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 /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public , T Driven Gauge of Casing t <br /> Irrigation I Gravel Pack Depth of Grout Seal <br /> Cathodic Protection t Rotaryj _ _Type of Grout 4 <br /> Disposal 1 Other Other Informationy <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: State Work Done OL, <br /> �,-." <br /> PUMP '.REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Di, meter <br /> Approximate Depth <br /> P p <br /> Describe Material and Procedure—^— <br /> I hereby agree to comply -with all laws and regulations of ertithe San Joaquin Local Health District , <br /> and the State California paning 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 />'RIOR TO G OUTING AND A FINAL I SPECTION. <br /> SIGNED - TITLE _ <br /> I ( RAW PLOT PLAN ON REVERSE SIDE) -- <br /> k FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTEp BY DATE -?O --•77 1 <br /> WDITIONAL COMMENTS: <br /> 'E <br /> PHASE II GROUT INSPECTION PHAS II/FIN NSPE ION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426• Rev. 1-74 , 1/77: " 2m <br />