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SAN JOAQUIN LOCAL HEALTH DISTRICT . <br /> ' FOROFFICE USE: 1601- E. Hazelton Ave. , Stockton, Calif. <br /> h Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUNT' PE'MIT -RPermit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date', Issued 5,-- <br /> (Complete <br /> -(Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local. Health Diattict. ,for a permit-to:construct <br /> and/or install the work herein described. This application is made. in7-compliance withSanJoaquin ; <br /> County Ordinance No. 1862 and the Rules and Regulations of. the San- J.oaquin -l:ocal'Health District. <br /> JOB ADDRESS/LOCATION YCENSUS= TRACT •^ <br /> Owner's Name _ /�'i' i7 R Phone <br /> Address -_. . <br /> Contractor's Name /r�rf " lf�_ License & 9%Vf Phone JW.491ro <br /> TYPE OF WORK �(Check): NEW WELL / DEEPEN -/-7 RECONDITION /_7 DESTRUCTION /_7 -- } <br /> PUMP INSTALLATION / ' PUMP REPAIR ../-7 PUMP REPLACEMENT 17 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK IS LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL-.,:�f`PUBLIC DOMESTIC WELL p� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION. SPECIFICATIONS "V <br /> Industrial _Cable Tool Dia. of Well Excavation l0 <br /> Domestic/privateDrilled Dia. of Well Casing f <br /> Domestic/public ,� d Driven Gauge of Casing _ <br /> Irrigation Gravel Pack Depth of Grout Seal ol <br /> Cathodic Protection Rotary Type of Grout _ ,�, <br /> Disposal Other Other Information <br /> Geophysical, Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 12,„r '.. <br /> Type <br /> yP Pump �� H.P.H,P � <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 1EPAIR: /7 State Work Done <br /> ,DES;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 /> and the State of California- pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completionof my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of well and notify them before putting. the..well in.use.. The above <br /> information is true t he-beat of my knowledge and belief. I WILL CALL FOR A -GROUT INSPECTION <br /> PRIOR TO GROUTING ANAL Et'T°I <br /> SIGNED sem' ITLE <br /> (DRAW PLOT PLAN ON REVERSE 'SI <br /> FOR- DEPARTMENT USE ONLY .. <br /> PILOSE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: - .. <br /> PHA& I QUT INSPECTION P INS PECrION <br /> INSPECTION BY DATE -2 -`- INSPECTION B AT <br /> H 1426 v i . . ,.._ . .. ,_..�.... . _.. . . �. �� <br /> E Rev. .1-74 -�4 2M <br />