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- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFifOFFTCE USE: 1.601 E. Hazelton Ave. , Stockton, Calif'. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 'S 3 o2fo� <br /> THIS PERMIT EXPIRES I 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 wade 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 R % ENSUS TRACT ®f,t- ZO-Z,.>- <br /> 11 <br /> ZI1 <br /> (wrier v s Name ;i. �� Phone 3 3 6-2-o <br /> Addres r / City <br /> contractor's Name <br /> License rheas 3 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_7 RECONDITION /7 DESTRUCTION r7 N <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT 'AJ, - tl <br /> 0 Other / / O <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL- FIELD CESSPOOL/SEEPAGE PIT 'OTHER i <br /> ib PROPERTY LINE PRIVATE DOMESTIC WELT. 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 /> -Itrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Otherr Other Information <br /> Geophysical 'Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. / <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP ,REPAIR: State Work Done <br /> RES TRUCTION OF WELL: Well Diameter Approximate Depth <br /> - Describe Material and Procedure <br /> € I <br /> I hereby agrali to comply with all laws and regulations of the San Joaquin Local Health Distri t <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DA , <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 i <br /> PRIOR TO GR0gZINp ANDA INAL INSPECTION. <br /> SIGNED TITLE <br /> RAW PLOT PLAN -ON REVERSE SIDE <br /> i FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE i <br /> ADDITIONAL COMMENTS: ? <br /> PHASE II FOUT INSPECXON PHASE III FINAL INSPECTION <br /> INSPECTION BY' J DATE INSPECTION- BY DATE <br /> j1 E R 1426 Rev. 1-74 1-74 M <br />