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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> OFFICE USE: 1601 E. Hazelton Ave. Stockton Calif. <br /> Telephone: (209) 466-6781 . <br /> APPLICATION FOR WELL CONSTrUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED :$ate',-1!4u601 �c4w,06 <br /> (Complete In Triplicate) 111-71L-04 )I:`.>i RIOT <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 h Ru1 s an egulations of t San Joa in Local Health District. <br /> JOB ADDRESS/ ON Q(% CENSUS TRACT <br /> Owners Name Phone <br /> ,t <br /> Address City <br /> Contractor's Name License//D-5 '5Phone .A)t4gg 0* <br /> y . . <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN I / RECONDITION f-1 DESTRUC IOS ./� <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT ` <br /> Other l I ,. <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 WELL <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 ¢A <br /> /p Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout � f <br /> Disposal Other Other Information <br /> Geophysical Surface_Seal_Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Do <br /> PUMP .REPAIR: / / State Work Done 4 <br /> DESTRUCTION 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 Locai.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 TITLE <br /> D W P PLAN 'ON REVERSE SIDE '� <br /> FOR PARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPT <br /> PtCo ' DATE <br /> ADDITIONAL COMMTS: <br /> PHASE II 9R,OUT INSPECTION PHASE III/FINAL INSPECTION . <br /> INSPECTION BY DATE INSPECTION BY DATE /D Z6 �eS <br /> E H 1426 Bev, 1-74 .. <br /> 3/76 20` <br />