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SAN .JOAQUIN LOCAL HEALTH DISTRICT <br /> F -OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (203)• 466-6781 <br /> AP tiCATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.�!6 _44ggW <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 .Heslth District. <br /> JOB ADDRESS/LOCATION d1� L 4 r CENSUS TRACT <br /> Owner's Name Q rz Phone , + <br /> Address fir. <br /> cityZL91t , <br /> ' <br /> Contractor's Name Y License d Phone 0 .�,2 <br /> TYPE OF WORK (Check): NEW WELL '/&? DEEPEN /7 RECONDITION 1-7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR /-7 PUMP REPLACEMENT /7 <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 /> r_`� Industrial k —Cable Tool Dia. of Well Excavation <br />' _ li--Domestic/private :1 Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Pr_otectioi Rotary Type of Grout <br /> Disposal OtherOther Information <br /> Geophysical Surface Seal Installed B <br /> yi <br /> PUMP INSTALLATION: Contractor � <br /> `Type .of Pump H.P. <br /> PUMP REPLACEMENT: . V,.—/ "-State Work Done 4 <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe MaterialNand Procedure 4 <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,wa:rk on a new well , I will furnish the San Joaquin Local Health District a j <br /> WELL DRILLERS REPORT of the well and notify-them-before putting.. the..well. in.use... The above I <br /> information is true. to-the-best-of-:my..knowledge and belief. I WILL CALL 'FOR A 'GROUT INSPECTION F <br /> PRIOR TO GROUTING ' .FTN NSPECTION. <br /> SIGNED TITLE <br /> } DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY i <br /> PHASE I �. <br /> APPLICATION' ACCEPTED BY DATE <br /> ADDITIONAL, COMMENTS: <br /> PHASE 11 GROUT INSPECTION., P SEI FIN INSPECTION I <br /> INSPECTION BY DATE INSPECTION BY - DATE _ <br /> E H 1426 Rev. 1-74 h/7q 2M <br />