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SAN JOAQUIN LOCAL HEALTH DISTRICT t <br /> : FOBf'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP .PERMIT Permit No. T�IIfpo <br /> THIS PERMIT.EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3-2s-7 <br /> (Complete In Triplicate) <br /> Application is hereby made tol.the San Joaquin Local Health District for a permit to construct <br /> and/or install theworkherein described. This application is made in compliance with San Joaquin <br /> County Ordinance No.,-1862 .and� t a ulee and Regulationi,,PtS aquin Local Health District. <br /> /D -�' <br /> 30B ADDRESS/LOCATION CENSUS TRACT� <br /> Owner's Name .�.�' Phone <br /> Address / .1/ .. 4 City <br /> ' , � <br /> Contractor's Name = i% � License 3 7nej <br /> TYPE OF WORK (Check): NEW WELL /_T DEEPEN /7 RECONDITION /7 DESTRUCTION 17 <br /> MP � <br /> PUINSTALLATION PUMP REPAIR /� PUMP REPLACEMENT f7 <br /> Other.I/ / <br /> DISTANCE TO NEAREST: SEPTIC. TANK SEWER LINES PIT PRIVY <br /> SEWAGEIDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE .. PRIVATE DOMESTIC WELL: ' PUBLIC'DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 'i 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 /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: 1 I State Work Done <br /> PUMP'.'REPAIR:-:-­.;::.... <br /> 2ES•TRUCTION OF WELL: Well Diameter 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 of. my knowledge and belief. I WILL CALL FOR A-GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED t� TITLE <br /> t (DRAW PLOT PLAN ON REVERSE SIDE <br /> ! FOR DEPARTMENT USE ONLY <br /> PHASE I r�✓ <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA E I FINAL INSPECTION <br /> INSPECTION BY JDATE 4 INSPECTION- BY DACE <br /> E H 1426 Rev. 1-74 '' "�1=74 '2M: '{ <br />