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Y SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: .i 1601 E. Hazelton Ave. , Stockton, Calif. b�I <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <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 aGperrnit 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 /> .11 <br /> .JOB ADDRESS/LOCATION SAlh ltea:aeA R1, A11,4 � � etZ CENSUS TRACT <br /> I` <br /> Owner's Name c Q Phone <br /> Address <br /> I� City lh—k7r«v <br /> Contractor's Name <br /> .Le/I f t a&J*A 4 �,t, License #;7,2y Phone/„ <br /> TYPE OF WORK (Check) ; NEW WELL / / DEEPEN /_/ RFCONDITION•-/ ./., BEST-RUCTION-/-7 <br /> PUMP INSTALLATION / / PUMP REPAIR_/-/-7-P' REPLACEMENT /4- <br /> Other <br /> DISTANCE TO NEAREST_: SEPTIC,TANK SEWER LINES PIT PRIVY <br /> �,e.,...�SEwAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> " F PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> ""INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing . <br /> Irrigation I Gravel Pack Depth of Grout Seal 1 <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other F Other Information <br /> Geophysical Surface Seal Installed B : <br /> 9 <br /> PUMP INSTALLATION: Contractor C <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /&/ State Work Done4AAveOtY <br /> PUMP -.REPAIR: <br /> / lh/ State Work Done <br /> DESTRUCTION OF WELL: We'll 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 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 OUTIN AND A FINAL INSPECTION. <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIE} <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ` .� <br /> APPLICATION ACCEPTED BY ! DATE <br /> ADDITIONAL COMMENTS: , <br /> PHASE II GROUT INSPECTION t PHAS I_,,_/FIN,4L INSPECTION <br /> INSPECTION BY 11 <br /> `1 DATE i INSPECTION BY DATE s'•= �� <br /> E H 1426 Rev. , 1-74 .�� -. -- `� 6/77 . 2M � <br />