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SAN JOAQUIN LOCAL 'HEALTH DISTRICT <br /> FOrOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 17 _8'p a" <br /> ---------THIS—PERMIT---EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> ,Application is hereby madejto 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 Joaqui <br /> County Ordinance No. 1862 and the Rules and Regulations of the San- Joaquin Local health District. <br /> t <br /> JOB ADDRESS/LOCATIO917 N <br /> CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address qpq <br /> City . <br /> Contractor's Name License #&2-�` /PhoneJdg-�3393 <br /> a <br /> TYPE OF WORKNEW;Check} � � <br /> ( WELL '%?`�DEEPEN�/_,�7,kCONDITION /__7 DESTRUCTION f7 <br /> PUMP' INSTALI:ATION , P- REPAIR `/ / PUMP RLACEMENT <br /> Other <br /> / /-�----=---w__,• — . EP., of <br /> 'DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD <br /> CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC'WELL <br /> INTENDED USE iTYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> industrial :1 Cable Tool Dia. of Well Excavation <br /> T Domestic%private !��� Drilled Dia. o€iWil Casing <br /> Domestic/public s Driven Jd p <br /> Irrigation Gauge.oCasing <br /> Gravel Pack Depth of Grout Seal <br /> E Cathodic Protection Rotary Type of Groixt' <br /> Disposal Other Other Information <br /> 3 Geophysical �-� Surface Seal.- Installed By: <br /> PUMP INSTALLATION: / <br /> Contractor "'��' � �/ <br /> Type of Pump « �,; <br /> ' HSP' <br /> PUMP REPLACEMENT: / State Work Done <br /> PUMP '.REPAIR: /_7 State Work Done <br /> t r <br /> ES.TRUCTION'OF WELL: Well Diameter f"" <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply with all Taws and regulations of the Sax Joaquin Local Health District <br /> and the State of California pertaining to or regulating weil 'construction. Within FIFTEEN DAYS <br /> after completion of my work 'on a new well, I will .furni,sh the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the .well and notify them before put'ting the.-well in-use.. The above <br /> information is true to the.hest of my knowledge and belief.1—I WI-LL.. CALL FORA GROUT INSPECTION <br /> LR TO ROUTING AND A FINAL INSPEG"YION: <br /> ED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I �r FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE r <br /> ADDITIONAL, COMMENTS: t <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY PHASE III FINAL INSPECTION <br /> DATE INSPECTION BY D E <br />� E H 1426 <br /> _ - Rev. I-74 <br />