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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO ;*OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6. 781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. a--5-2-31- <br /> THIS <br /> -Sa 31THIS 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 ales d Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Ownera Name C�9 Y � � �-v Phone U <br /> Address <br /> � <br /> '! <br /> Contractor's Namex �._ �, � � � u� .License' l/ � .k:::�.f�honeV���� . <br /> TYPE OF WORM (Check): ' NEW WELL /7 DEEPEN '/7 RECONDITION -/_7 DESTRUCTION f7 <br /> PUMP INSTALLATION / / PUMP REPAIR /7 PUMP REPLACEMENT Iy <br /> Other <br /> 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 �V1 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing wl <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: G <br /> PUMP INSTALLATION: 'Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . State Work Done.�4, 7 77401�4� <br /> PUMP`'REPiAIR: / State Work Done <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 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 GR TING AND A FINAL INSPECTION. <br /> SIGNED 2M TITLE - <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INIPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY - DATE j <br /> y t1 <br /> x/75- <br /> E 1426 Rev. 1-74 _ _ <br />