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S _ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: 1601 E. Hazelton '-Ave. , Stockton, Calif. <br /> Telephone: Ij (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.J - <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued7e <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. 1.862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION qA CENSUS TRACT <br /> Owner's NaasRLCI.L5 I <br /> Phone $-?- - <br /> !Wdress 5 City <br /> contractor's Name' License #c�2��Gd'1' 3 Phone n 40- <br /> TYPE OF WORK (Check): NEW WELL /�(7 DEEPEN 17 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR /-7 PUMP REPLACEMENT 17 i <br /> Other / 7 --- I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY N <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER C ; <br /> PROPERTY LINE - PRIVATVDOMESTIC WELL - PUBLIC DOMESTIC WELL pb y <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 /> Irrigation Gravel Pack' Depth of Grout S al r <br /> Cathodic Protection Rotary Type of Grout <br /> DisposalOther Other Information <br /> Geophysical. <br /> • .. - Surface Seal Instilled By: <br /> PUMP INSTALLATION: Contractor „I <br /> Type of Pump H.P. i <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: L7 State Work Done 1 <br /> ES1RUCTION OF WELL: Well Diameter - Approximate Depth f <br /> Describe Material and Procedure <br /> I <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 ROUTING AND A FINAL INSPECTIO � <br /> SIGNED TITLE <br /> DRAW -PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY I <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE I.4 <br /> ADDITIONAL COMMENTS: t <br /> PHASE II GROUT INSPECTION P III FINAL INSPECTION <br /> IIu`SPECTION BY DATEINSPECTION BY DATE - * . ' <br /> .,_. ' <br /> v u <br /> I E H 1426 Rev. 1-741-74 lu r <br /> i <br />