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*. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF�:OFFICE USE: 16011. E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Pe m o. 2",-( �. <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 �n / CENSUS TRACT <br /> Owner's Name SRL, u a z, Phone <br /> Address City ' <br /> Contractor's Name j f even- - o p c1 License # Phone Za?=-s�7 Zok4 <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN /7 RECONDITION /7 DESTRUCTION /=T <br /> AL <br /> PUMP INSTLATION PUMP REPAIR -/_7 PUMP REPLACEMENT /7 Y <br /> Other 5 �.�:1 i"1, <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 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 <br /> Domestic/private Drilled Dia. of Well Casing <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 Seal Installed B : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP. .REPAI--R:-. - / P—State"Work 'Dohs - ` - <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 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 /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> �- PHASE I <br /> APPLICATION ACCEPTED BY DATE W9)6 <br /> ADDITIONAL COMMENTS: <br /> ` PHASE II GROUT INSPECTION PHASFellIlFINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE Y-z' G <br /> E H 1426 Rev. 1-74 4/75 <br />