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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORrOFFICE USE. 1601- E. Hazelton Ave. , Stockton, Calif. <br /> i <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PEtMZT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR .PROM-DATE ISSUED T' Date- Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health.,District:Tor 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/LOCATIONE' aCENSUS:TRACT= <br /> 41 <br /> Owner's Name /re-A*? Phone <br /> Address <br /> Contractor's Name � r., x/mss' License #ZAV Phone 9C <br /> TYPE OF WORK (Check): NEW WELL /5;1 DEEPEN/-7 RECONDITION /_7 DESTRUCTION F7 <br /> PUMP INSTALLATION / ' PUMP REPAIR /� PUMP REPLACEMENT <br /> Other <br /> I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER U4 <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL''1. ' PUBLIC DOMESTIC WELL pp <br /> INTENDED USE TYPE OF WELL CONSTRUCTION. SPECIFICATIONS �V <br /> Industrial _. Cable Tool Dia. of Well Excavation Q <br /> _ X Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing _ �fc_.�s. /�Q G N <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 /> PUMP INSTALLATION: Contractor / �� ,,r <br /> Type of Pump . efm 4, A.P. <br /> PUMP REPLACEMENT: / IT State Work Done <br /> PUMP `.REPAIR: /7 State Work Done <br /> J01RUCTION 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 well and notify them'before putting. the..well in use.. The above <br /> information is true-t ' he•b est of my knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GROUTING AL SF-ECT- <br /> SIGNEDTTLE <br /> -DRAQ PLOT PLAN ON REVERSE 'SI <br /> FOR-DEPARTMENT USE ONLY - � <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE S <br /> ADDITIONAL COMMENTS: Al <br /> P14E 14,SEOUT INSPECTION P INS ECTION <br /> INSPECTION BY DATE INSPECTION- B AT <br /> .�-�':E S 1426 . Rev. 1. 74 �.. •- - -�., .� __. _.- .. . __ 1-74 ?M ��� <br />