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SAN JOAQUIN LOCAL HEALTH DISTRICT I <br /> AIE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> SSS' s�-[a '' cc`�w. -=/�/ f (Complete In Triplicate) /D8- . 2-s c, z� 1 <br /> Application is hereby made to the San Joaquin Local Health District foreermit to con <br /> struct <br /> and/or.install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 18 2 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name ACV <br /> Phone 77 <br /> Address <br /> City <br /> Contractor's Name <br /> a , License # Phone y,1z- s9y <br /> TYPE OF WORK (Check)`., NEW WELLDEEPEN •/? RECONDITION /7 DESTRUCTION /7 <br /> ' PUMP INSTELATION j/1 PUMP REPAIR /`7 PUMP REPLACEMENT <br /> 4 Other 17 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD <br /> CE SPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL '-- PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL. t _ CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia.' of Well Excavation <br /> Domestic/private <br /> Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal ' <br /> Cathodic Protection Rotary Type of Groeit <br /> ' Disposal <br /> Other-lufo <br /> Geophysical Other rmatiou <br /> Surface Seal Installed By: <br /> n� <br /> PUMP INSTALLATIONe Contractor <br /> Type of Pump �- <br /> H.P. <br /> PUMP REPLACEMENT: %/ State Work Done T ?� <br />—PU-M.P REPAIR: ? State Work t r <br /> Done <br /> ES.TRUCTION OF WELL: Well Diameter <br /> F Describe Material and Procedure Approximate Depth <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 to the-best of my knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GRMMTN6 AN FI AL INSPECTION. <br /> SIGNED <br /> r TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I { FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED--BY <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION <br /> ! , . PHASE `III FI INSPECTI N <br /> INSPECTION BY w_ DAT INSPECTION BY <br /> E H 1426 Rev. 1-74 <br /> 1-7� t <br />