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ISAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0 OF- ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> ` Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �. ±191 <br /> THIS PERMIT -EXPIRES I YEAR FROM DATE ISSUED Date Issued7$- <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. 1.862 and the Rules and Regulations of thePay Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION J 3 L(f CENSUS TRACT <br /> Owner's Name Phone a j. J.-I- <br /> Address City , � <br /> Contractor's Name/11�e /tel icense PhoneF,-7lsx? <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION /% DESTRUCTION /7 <br /> j PUMP INSTALLATION _/ / PUMP REPAIR / / PUMP REPLACEMENT f <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 /> 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 Driven Gauge of Casing <br /> Irrigation Gravel. Pack Depth of Grout Seal <br /> t Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information- _ <br /> Geophysical Surface Seal Installed BY:, <br /> PUMP INSTALLATION: ContractorC��� - <br />! Type of Pump H.P. / <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: / / State Work Done <br />' DES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> 'Describe Matdrial 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 t he best of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AN F1 INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 15= <br /> ADDITIONAL COMMENTS: -- <br /> PHASE II GROUT INS CTION PHASE II/FI AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 2M <br /> 7 <br /> �ETH'"142'6A-�- -;Rev-. . 1-74 <br />