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_ SAN JOAQUIN LOCAL':HEALTH DISTRICT <br /> FOE'; FFICE 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 MIRES1,YEAR°PROM DATE ISSUED Date Issued s-25"' 7 <br /> (Complete -ln...Triplicate) <br /> Application is hereby made to1the 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 rR Regulations ,of the San Joaquin Local ]Health District. h <br /> JOB ADDRESS/LOCA CENSUS TRACT - <br /> (haver s Name Phone <br /> Addresses . ,�j f7 j. -✓c � City <br /> Contractor's.Name 'Z)X=-z-77�9� PV A-1 E" License Phone <br /> TYPE OF WORK (Check): NEW WELL /� DEEPEN /� RECONDITION /_� DESTRUCTION <br /> PUMP INSTALLATION / I PUMP REPAIR /7 PUMP REPLACEMENT <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER. LINES PIT PRIVY <br /> •r SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL Q <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS C�ljl <br /> Industrial Cable Tool Dia. .of Well Excavation <br /> Domestic/private 11 Drilled Dia. of Well Casing (/) <br /> Domestic/public I .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: <br /> ; .- " . + <br /> PUMP INSTALLATION:.: W Contractor <br /> Y Type of Pump H.P. <br /> PUMP REPLACEMENT: / State Work Done <br /> PUMP :RTPAIR:., /7 .,State Work Done <br /> , S f _.-+ar.. - • .. .r �®- qt. r._ a. ter-.--. ' <br /> ES:TRUCTION OF_WELL: Well iometer 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 wil; 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 INSPECTION. <br /> SIGNET} TITLE G <br /> r (DRAW PLOT •PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> t• PHASE I <br /> APPLICATION ACCEPTED BY ° DATE <br /> ADDITIONAL COMMENTS:. <br /> PHASE II GRO10T INSPECTION PHASE I I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY u r DATE <br /> �t E H 1426 Rev. 1-74 1-74 2M <br />