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r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORiOF ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _.3 F3_ <br /> THIS PERMIT EXPIRES .1 YEAR FROM DATE ISSUED Date Issued7� <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 AOCATION 627c— 1 4r CENSUS TRACT <br /> Owner's Name { e <br /> At 04. 4 Phone <br /> Address ("2 ��, _ City <br /> Contractor's Name License # 72SPhone <br /> TYPE OF WORK (Check): NEW WELL '/_7 DEEPEN /7 RECONDITION /_7 DESTRUCTION f7 <br /> I PUUhMPPrl/?ELATION / / PUMP REPAIR &eY PUMP REPLACEMENT /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER V <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 Qr, <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 By: <br /> 4 _ <br /> f ' PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PM .REPAIR: State State Work Done ,1 <br /> ES1RUCTION 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 kno=and-b-elief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECPI N. <br /> SIGNED LE <br /> D WAP T' PLAN ON REV E SIDE <br /> DEPARTMENT USE ONLY <br /> PHASE I <br /> I APPLICATION ACCEPTED ,BY DATE <br /> ADDITIONAL COMMENTS: - ' <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPE <br /> I INSPECTION BY DATE INSPECTION BY DA <br /> E H 1426 Rev. 1-74 +; <br /> 1-74 2M <br />