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SAN JOAQUIN LO AL­�ALTH. DISTRICT <br /> POR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL 'CONSTRUCTION OR PUMP PERMIT Permit No. � . <br /> p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3-0'— <br /> (Complete <br /> _8—(Complete In Triplicate) <br /> Application is hereby made to the Saxe 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/ 1 CENSUS TRACT <br /> Owner's Name - ` � ��� ��" Phone <br /> Address 94r--514AI19LA —5"P44,07City <br /> Contractor's Name 0 Inl License # hone <br /> h <br /> Z <br /> TYPE OF WORK (Check) : NEW WELL Lyl DEEPEN / / RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION /X—PUMP REPAIR/—/—PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 7C-PIT PRIVY <br /> SEWAGE DISPOSP FIELD CESSPOOL/SEEPAGE PIT/ 41 �$THER --'�- <br /> PROPERTY LINE PRIVATE DOMESTIC WELL P� PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL '. CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> _ Domestic/private r Drilled Dia. of Well Casing /it tin (u <br /> Domestic/public Driven Gauge of Casing L i <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 all—S j <br /> Type of Pump ,.� be H.P. <br /> PUMP REPLACEMENT: ' /"/ State Work Done <br /> PUMP -REPAIR: / / StateiWork Done <br /> DESTRUCTION OF WELL: Well. Diameter Approximate Depth <br /> Describe-,Mate'r'ial 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- knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTIO e <br /> SIGNED TITLE <br /> Pl'+ T TLA N REVERSE SIDE)' <br /> FOR DEEfRTMENT USE ONLY + <br /> PHASE I ; <br /> APPLICATION ACCEPTED BY DATE .-�7 <br /> ADDITIONAL COMMENTQ/* <br /> PHA UT INSPECTION PHAq4 ITTJFIAL INSPECTION <br /> INSPECTION BY AVr1, DATE INSPE TION BY ..—DATE <br /> 1-7 <br /> E H 1426 Rev. I-74 -` 31 6 2M <br />