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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOB OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781. , <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7ti�� 9y�✓ <br /> /THIS. PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued <br /> (Complete In Triplicate) 2-V3 �- eyv 3a <br /> Applicatiod' is`t:ereby'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. 862 and the Rules ddR'e.'ggula o s� tSaat Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONlv�j, ted- �rrs�' <br /> /"� CENSt15 TRACT <br /> Owner's Name Ph6fie� �� <br /> Address (7`"1 C5,, City d1f <br /> Contractor's Name 0 - - Licensee"3Phond ""4� � <br /> TYPE OF WORK (Check) : NEW WELL /7 DFEPEN,'',/?. RECONDITION f7 DESTRUCTION /7 ry <br /> PUMP 'INSTALLATION ./ / PUMP REPAIR .2 PUMP REPLACEMENT /? <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 <br /> INTENDED -USE } TYPE OF WELL CONSTRUCTION SPECIFICATIONS �NI <br /> Industrial 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 /> ' PUNP REPLACEMENT: / / State WorkDone - <br /> PUMP '.REPAIR':. �.�P r= <br /> /r :State#Work D �. ='h <br /> PES4RUCTION 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 DAYt u <br /> ; after completion 'of my work on a new well, I will furnish the San Joaquin Local Health District �- <br /> WELL DRILLERS REPORT of the well: and notify them before putting.. the..well in.use.... The above tL <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 TITLE <br /> - (DRAW PLOT PLAN ON REVERSE SIDE12=&FOR DEPARTMENT USE ONLY <br /> PHASE I r <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> I PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> ! INSPECTION BY DATE INSPECTION BY DATE La <br /> x <br /> E H 1426. Rev. :1-74 - ` h/75 2M <br />