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SAN JOAQUIN LOCAL- HEALTH DISTRICT <br /> 'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ` <br /> Telephone: (209) 466-5751 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. =��>�lr/ <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. 1852 and the Rules and Regulati s of the San Joa uin Local Health District. <br /> JOE ADDRESS i1 F4 9 CENSUS TRACT <br /> 3q <br /> Owner's Name -� Phone — <br /> .c <br /> + r <br /> E <br /> Address. - -7 City <br /> Contractor's Name .f License #/<6:2373 Phone 3 LL3�- <br /> 1 <br /> TYPE OF, WORK (Check): NEW WELL - DEEPEN 17 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION 0 PUMP REPAIR /7 PUMP REPLACEMENT f-7 <br /> Others /7 <br /> 1 i <br /> DISTANCE TO NEAREST: SEPTTCITANK SEWER LINES PIT PRIVY <br /> f SEWAGE DISPOSAL FIELD �,�yr CESSPOOL/SEEPAGE PIT OTHER {',, <br /> PROPERTY LINE - PRIVATE DOMESTIC-WELL I'! PUBLIC DOMESTIC WELL <br /> INTENDEDvO1 <br /> 1 �USE -4- rtTYPE,OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial s Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing69 <br /> Domestic/public t-A ,'Driven Gauge of Casing / a--- <br /> Irrigation I Gravel' Pack Depth of Grout Seal <br /> Cathodic Protection F iRotary Type of Grout' <br /> Disposal t 06er Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / i/ State :Work Done <br /> -PUMP REPAIR: tat -Work-Done <br /> L&TRUCTION 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 /> t 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 G i AN INAi INSP CTION. 2)t-,-0 <br /> `� ,, <br /> SIGNED TITLE/�' <br /> W PLOT PLAN ON REVERSE SIDE <br /> DEPARTMENT USE ONLY <br /> F PHASE I <br /> APPLICATION ACCEPTED DATE h� <br /> ADDITIONAL COMMENTS: <br /> PHASE I TMNSPZCIMPS II FINAL INSPECTION <br /> INSPECTION BY DAT9 INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 1-74 2M <br />