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SAN JOAQUIN LOCAL HEALTH DISTRICT -- <br /> FOR,0 F CE USE: V Z1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z-,3 3.3-3� <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 AOCATION pn7 CENSUS TRACT <br /> Owner's Name Phone <br /> Address �a <br /> City <br /> Cattractor's Name <br /> License # jj6,5,&1 V Phone j�)'26 <br /> TYPE OF WORK (Check): NEW WELLX DEEPEN/'7 RECONDITION /7 DESTRUCTION /`T <br /> €'. PUMP INSTALLATION /�/ PUMP REPAIR / / PUMP REPLACEMENT <br /> other 7 <br /> j -- <br /> DISTANCE TO NEAREST: SEPTIC TANK lob SEWER LINES PIT PRIVY <br /> - <br /> `SEWAGE DISPOSAL FIELD --, - ~CESSPOOL/SEEPAGE PITI— _OTHER __"_.. <br /> ` —PROPERTYx-EINE•--PRIVATE°DOMESTIC WELL" _PUBLIC'DOMESTIC'WE ;I. <br /> INTENDED USE TYPE OF WELL <br /> -- CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation : <br /> Domestic/private' , Drilledke <br /> Dia.~ of Well Casing 4 <br /> Domestic/public Driven f Gauge of Casing j Q 9-I <br /> t uww <br /> Irrigation Gravel Pack Depth of Grout Seal 5 p �- <br /> -Cathodic Protection Rotary Type-of Grout <br /> Disposal Other `+ Other Information__ -- . <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: _ <br /> Contractor„ �� � <br /> Type of Pump H.P. �D <br /> PUMP REPLACEMENT: State Work Dane <br /> PUMP .REPAIR: )S7_ State, Work Done. _ <br /> ES TRUCTION_OF WELL: <br /> Well Diameter •r <br /> Approximate Depth <br /> Describe Mater-41 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 FORA -GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: -DATE �'b J 7_5 <br /> PHASE JIIGROUT4INSPECTION PHASE UIJFINAL INSPECTION <br /> INSPECTION BY ATE; �.S INSPECTION- BY d ' DATE <br /> ^E-H 1426 Rev. 1-74 <br /> 4 1-74 2M F <br />