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--r SAN JOAQUIN LOCAL HEALTH DISTRICT'd-s.•` •r G <br /> FOL�OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. i! / <br /> Telephone: (209) 466-6781 7G <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> I <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/LOCATION (p J ' CENSUS TRACT <br /> Phone <br /> Owner's Name <br /> Address <br /> C0"P City <br /> ' C � �II�ILUNG�_ License #,7 3 Phone <br /> Contractor s Name <br /> YPE OF Check) : NEW WELL / DEEPEN / / RECONDITION / / DESTRUCTION /�T <br /> T WORK ( PUMP''2INSTA�LLATION / / PUMP REPAIR / PUMP REPLACEMENT /-7 <br /> O thers Z77 <br /> DISTANCE TO NEAREST: SEPTIC TANK d SEWER LINES Z±6 PIT PRIVY <br /> SEWAGE DISPOSAL FIELD Jab / 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 f/r` <br /> 4 e7 Domestic/private Drilled Dia. of Well Casing ` <br /> Domestic/public -- <br /> Driven Gauge of Casing _ `U 0 <br /> I Irrigation ,C Gravel Pack Depth of Grout Seal N <br /> Cathodic Protection {_�_ Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical. Surface Seal Installed By:_ <br /> 770 <br /> PUMP INSTALLATION: Contractor -12 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> k <br /> PUMP .REPAIR: / / 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 furAAh the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them beforeputting the -well in use. The above <br /> f information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU G AND A FINAL-INSPECT; <br /> SIGNED, TITLE .tJ; <br /> WPT; T PLAN 'ON RE ERSE SIDE) <br /> i FOR DEPARTMENT USE ONLY <br /> PHASE I -�7 <br /> r <br /> APPLICATION ACCEPTED B DATE L. <br /> ADDITIONAL COMMENTS: PHAS dI/FI INSPECTION <br /> PHASE II GROUT INSPECTIO DATE <br /> INSPECTION BY DATE ip INSPECTION BY <br /> f <br /> l yo l.�� 1 014-;1k- ,. V.P - I;'r '`' " <br /> �, .�, 3 16 211 <br /> e E H 146; Rev. 1 74 � <br />