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I <br /> Gd' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOB.OFFICE USE: 41601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION .OR PUMP PERMIT Permit No. 7 6- S'391° <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> r (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. Health District. <br /> JOB ADDRESS/LOCATION~ . , /o� U i t el CENSUS TRACT <br /> Owner's Name !1 Phone <br /> Address f{ City <br /> Contractor's Name c�� License # ry����P oh ne y�G7V <br /> TYPE OF WORK (Check): NEW WELL/� DEEPEN 'j RECONDITION I7 DESTRUCTION f7 <br /> PUMP !INSTALLATION "/ / PUMP REPAIR / PUMP REPLACEMETTT <br /> t 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 p� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS N <br /> Industrial. I Cable Tool. Dia. of Well Excavation a <br /> _ Domestic/private i 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 Grout ' <br /> Disposal i Other Other Information <br /> Geophysical ,{ Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type. of Pump ' -° --- - ,� H.P. <br /> t <br /> PUMP REPLACEMENT: /K/ State Work Done f � ID <br /> , + <br /> PUMP .REPAIR: / / 4 State Work Done , <br /> ~ _ <br /> F <br /> DE&TRUCTION 'OF-WELL: Well'iDiameter 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 /> information is true to the•best 0fMqjMowledRe and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR UT NG -AND A FINAL INSP IO <br /> SIGNED TITLE <br /> l D PLT PLAN ON MVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 11 <br /> APPLICATION' ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> ` PHASE II GROUT>INSPECTION PHASE MINAL INSPECTION <br /> M INSPECTION BY DATE INSPECTION BY. DATE e7 —bl-7fe <br /> k` E H 1426 RPt,. 7_74.x. » , 2m <br />