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r �4 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE.OFF E USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> p , <br /> jLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,pa <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 Joaquit <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 1C- -atA. e CENSUS TRACT <br /> L Owner's Name ; (�� (�moat --—_—— Phone <br /> Address City <br /> Contractor's Name License # 145d hone 0 , <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN %/ RECONDITION /_/ DESTRUCTION /-7' <br /> AL <br /> PUMP INSTLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT /_ <br /> Other /_7 ,. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> 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 /> Irri ation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical K Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> ✓ H.P. _ 4L <br /> Type of Pump <br /> PUMP REPLACEMENT.: / / State Work Done // C <br /> PUMP .REPAIR: / / 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 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 f , know edge nad belief. r WILL CALL FOR A GROUT INSPECTION <br /> C PRIOR TO GROUTING AND A FI. ISJ <br /> PECT <br /> SIGNED ,� TITLE <br /> �- PtOT PLAN ON - RSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE `'- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IN INSPECTION ' <br /> INSPECTION.BY DATE INSPECTION BY TE S zr 7 <br /> ' 1177 2M <br /> E H 1426 Rev. 1-74 <br />