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{ <br /> fL -A, - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFY,'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, :Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL 'CONSTRUCTION OR PUMP PERMIT Permit No. <br />{ <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 instal, 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 9fC 72CENSUS TRACT <br /> Owner's Name # , <br /> Phone ' <br /> �,,� C� rF <br />„ Address / ` �,� � ���__,. City <br /> Contractor's Name License # 766iiZ Phone L,1-,5,T`f7 <br /> TYPE OF 'WORKCheck : NEW WELL.' <br /> )g, )g DEEPEN /? RECONDITION f-7DESTRUCTION /7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR -/-7—PUMP REPLACEMENT--/-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTICiTANK SEWER LINES PIT PRIVY <br /> �s SEWAGE ;DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPER' Y LINE -- PRIVATE DOMESTIC WELL'. PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial .= Cable Tool-' - Dia. of Well Excavation /G Q`y <br /> Domestic/private i Drilled. Dia. of Well Casing -� <br /> Domestic/public Tel Driven Gauge of Casing ` - <br /> Irrigation = Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout ' <br /> Disposal - t Other. Other Information <br /> Geophysical Surface Seal Installed 'By: _ <br /> PUMP INSTALLATION: --- <br /> Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> P#MP .REPAIR.: / / State Work Done <br /> DESTRUCTION OF-WELL: Well Diameter Approximate Depth <br /> 1 <br /> I PP p <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the Sar: 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 /> 4 information is true to the-best-of my knowledge and belief. I WILL CALL FOR 'A GROUT IN . <br /> PRIOR TO GROUTING 'AK A F AL:INSPECTION. <br /> SIGNED 0 TITLE` dA i <br /> 1 (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br />' APPLICATION ACCEPTED BY DATE ' <br /> ADDITIONAL COMMENTS; -7/30 <br /> PHASE II ROUT INSPECTION PHASE III FINAL INSPECTION <br />' INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 1./7c om <br />