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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ` FOTrOFFICE USE: 1601 E. Hazelton Ave. , Stockton$ Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,7�a-,2 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 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 l !2"'10/$/ A k� CENSUS TRACT <br /> Owner's Name r Phone 41Z,2- <br /> Address <br /> 1 .2-Address City i <br /> Contractor's NameLicense Phone <br /> TYPE OF WORK (Check): NEW WELL /7KDEEPEN '/7 RECONDITION /7 DESTRUCTION �""'- <br /> PUMP INSTALLATION- L- PUMP REPAIR /-7PUMP REPLACEMENT L7 <br /> Other. / <br /> DISTANCE. TO NEAREST: - SEPTIC TANK �L $EWER LINES Z6,0 PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE- - PRIMA DOMESTIC WELL PUBLIC DOMESTIC WELL 1 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 1 <br /> Industrial Cable Tool Dia. of Well Excavation /-3 <br /> -_/Dome a tid/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 B ;,s1.x0- <br /> PUMP INSTALLATION: Contractor _ <br /> Type of Pump - .: H.P. <br /> PUMP REPLACEMENT: /-7 State Work Done <br /> PUMP :REPAIR: L7 State Work Done <br /> ES•TRUCTION OF"WELL: Well Diameter `'� Approximate Depth .,...111%p <br /> Describe Material and Procedure f;j <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health Distract <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 = TITLE J-1 = . <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY14) �1 DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PRASE III FINAL INSPECTION <br /> INSPECTION BY DATE /-,a 7- INSPECTION- BY DATE <br /> E S 1426 Rev. 1-74,2,, P10 � 6 1-74 2M <br />