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sr �� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOi10FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Peirmit No, 7S,241,,2iI:J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �3d 7c- <br />. ; A (Complete In Triplicate) <br /> pplication 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 /> p <br /> JOBr <br /> ADDRESS/LOCATION ZI 7;(S CENSUS TRACT <br /> c � <br />,.. .Owner's Name ' <br /> / Phone <br /> *'Address �" <br /> City i <br /> 7.Contractor's Name License # Phone <br /> ;TYPE OF, WORK Check) : J <br /> ( NEW WELL /� DEEPEN /_� RECONDITION /� DESTRUCTION _f <br /> PUMP INSTALLATION /_J PUMP REPAIR /? PUMP REPLACEMENT %f <br /> Other / 7 <br />•DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL W <br /> INTENDED USE TYPE OF WELL CONSTRUCTION 'SPECIFICATIONS a^! <br /> _ Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of- Casing,__ig <br /> Gravel Pack Depth of Grout Seal <br /> _ Cathodic Protection " 1 Rotary Type of Grout <br /> Disposal ' Other _ Other Information <br /> Geophysical Surface Seal. Installed By: r <br /> PUMP INStALLATION: Contractor r <br /> , Type of Pump H.P. <br /> { <br /> PUMP REPLACEMENT: / /5,'' State Work Done <br /> PUPPP :REPAIR: /? State Work Done <br /> ES;TRUCTION OF WELL: Well Diameter <br /> 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 /> informatio i true to the•b of- my knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TD U NG AND A FIN NSE ION. <br />,,SIGNEDA* TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHA- E I <br /> APb <br /> PLICATION ACCEPTED BY �r <br /> ADDITIONAL. COMMENTS: DATES <br /> PHASE II GROUT INSPECTION <br /> PHAUM. FINAL INSPECTION <br />"INSPECTION BY DATE •INSPECTION, BY DATE <br /> 5 <br /> i E H 1426 Rev. 1-74 <br />