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x _ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOEt OFFICE USE: 1601 E. Hazelton Ave; , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No,�?�- �,{1 <br /> THIS PERMIT EXPIRES l 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-Joaquiri <br /> County Ordinance No. 1862 aria the Ka-les and Regulations of the San 'Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name (� �, ' Phone <br /> Address t <br /> City <br /> x <br /> Contractor's Name ,. 3'... 4 License A.4!6a� 5— Phone <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN /? ! RECONDITION /7 DESTRUCTION f7 <br /> PUMP INSTALLATION 6�PUMP REPAIR/? PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD - ` :j-CESSP00L/.SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> ". INTENDED USE TYPE OF WELL t CONSTRUCTION SPECIFICATIONS �f <br /> Industrial Cable Tool Dia. of Well Excavation ` _A <br /> Domestic/private Drilled Dia. of Well Casin x� <br /> g , <br /> Domestic/public 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 Se'aI Installed 'B a o <br /> 3 <br /> PUMP INSTALLATION: Contractor <br /> ✓` Type of Pump - c.� X57. H.P. -f <br /> PUMP REPLACEMENT: . State Work~Done '* <br /> PUMP REPAIR: / / State Work Done <br /> DES;TRUCTION OF WELL: Well Diameter ? Approximate Depth <br /> ,,Describe Material and Procedure <br /> i •herebyzagree 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 co'pletlon of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS-REPORT of he well and notify them before putting- the-well in:use.... .The above -.. <br /> informat rue o t e•best.of my kn ledge and belief. I WILL CALL -FOR A -GROUT INSPECTION <br /> PRIOR S <br /> SIGNED ; <br /> TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE— <br /> PHASE i <br /> FOR DEPARTMENT USE ONLY 3. <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: Of e <br /> P 9 L7 <br /> PHASE II GROUT INSPECTION PRASE III F NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DAT <br /> E H 1426 _ <br /> Rev. 1-74 <br /> .� .._ <br /> - <br />