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LOCAL HEALTH DISTRICT <br /> FOF, FFICE USE: 1601 Hazelton .Ave::-, Stockton, Calif. <br /> Telephone: -(209) .466-6781 <br /> APPLICATION <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Noz__A� <br /> THIS PERMIT ,E)TIRES ,1>.YEAR:FROM DATE ISSUED Date. lesued/� <br /> (Complete :in Triplicate) ' <br /> Applicdtion is hereby made to the Sar. Joaquin.,Local w 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;.Regulation0 of the San Joaquin Local Health District;.; <br /> JOB ADDRESS/LOCATION 4S CENSUS TRACT <br /> OwnerPs Name F 8N o c. Phone <br /> Address D - City S 7XC lkl <br /> ® f <br /> Contractor's Name Ax License # x;!, 74,4 Phone V 3 ' <br /> TYPE OF WORK (Check).- NEW WELL /7 DEEPEN '/-T RECONDITION- /_7 DESTRUCTION .f_T 1 <br /> PUMP INSTALLATION / / PUMP REPAIR /=.I PUMP REPLACEMENT <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY j <br /> SEWAGE DISPOSAL FIELD CESSPOOL/.SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL (A : <br /> INTENDED USE TYPE OF WELL - - CONSTRUCTION SPECIFICATIONS._...,,.. �! <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private = : Drilled Dia: -of Weil- Casing " <br /> Domestic/public Driven Gauge of Casing <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 <br /> :PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work.Done <br /> PUMP ,.REPAIR: State Work Done .�. <br /> i <br />+ 4E&T.RUCTION 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 /> t information is true to the-best-of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR .7Y} GROUTING AND FINAL INSPECTION. <br /> t - <br /> TITLE <br /> - (DRAW PLOTLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 22 / <br /> ADDITIONAL COMMENT'S: <br /> PHASE II GROUT INSPECTION PHASE I INAL INSPECT QN /t <br /> INSPECTION BY DATE INSPECTION BY DATE U <br /> E t E H 1426 Rev. 1-74 A-" Fid d/tel j� ! 1-74 2 <br />