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SAN JOAQUIN LOCAs. HEALTH DISTRICT <br /> FOE.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 l YEAR FROM DATE ISSUED Date Issue1�Z <br /> (Complete In 'Triplicate) <br /> ApplicatJlon is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work hereia cation is made in compliance with San Joaquin <br /> County Ordinance Nv. 18 d;the lea and , Agula ons the San Joaquin Local Health District. <br /> JOB ;SsILOCATI ((?� - lvn CENSUS TRACT <br /> Owner's Name i Phone <br /> Address _ City . <br /> Contractor Is. Name �QD rlrlltw Licensed Phone /-vim /la <br /> TYPE OF WORK (Check): NEW WELL/ DEEPEN/-T RECONDITION /-7 DESTRUCTION f-7PUMP INST&LATION PUMP REPAIR -/-7—PUMP REPLACEMENT 17 <br /> Other /-7 <br /> DISTANCE TO 'NEAREST: SEPTIC TANK 3W SEWER LINES . PIT PRIVY <br /> SEWAGE DISPOSAL FIELD,3Z�) -/- CESSPOOL/SE GE PIT,;�W t OTHER �`- <br /> PROPERTY LINEPRIVATE DOMESTIC WELL • PUBLIC DOMESTIC WELLS <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> - Industrial X Cable Tool Dia. of Well Excavation / Z� Q <br /> Domestic/private Drilled Dia. of Well Casing V <br /> Domestic/public Driven Gauge of Casing at <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 BX: <br /> t <br /> PUMP INSTALLATION: Contractor ,s <br /> Type of Pump f H.P. <br /> PUMP REPLACEMENT / / State Work' Done <br /> PUMP ,.REPA.IR: / / State Work Done <br /> DES•„ T�RUCTION 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 GROUTING AND A FINAL INSPECTIO <br /> SIGNED LE <br /> W PLOT P ON REVERSE SID . <br /> FORD ARTMENT USE ONLY <br /> PHASE -I <br /> APPLICATION ACCEPTED BY DATE Z <br /> ADDITIONAL COMMENTS: <br /> PHA9E II G N ECTION PHASE III/FINAL INSPECTWN <br /> INSPECTION BY DATE /� INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 4/75 _`2M <br />