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1 <br /> SAN JOAQUIN LOCAL.-HEALTH DISTRICT <br /> JOS.OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 S <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, . -I-'7, 6 <br /> t <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6 <br /> ' (Complete In Triplicate) <br /> - <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 Joaquin <br /> County Ordinance No. 1862 andlthe Rules .and Regglations of the San Joaquin Local. Health Dist rtet. <br /> JOB ADDRESS/LOCATION 26 CENSUS TRACT <br /> ' Y W .. <br /> 1 <br /> Owner's Nameti,.�„-►gid .moi. Phone 1 <br /> Address O City ' ��^ <br /> Contractor's Name License # Phone , <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/- PRECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTICTANK 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 /> Irrigation t Gravel. Pack Depth of Grout Seal <br /> Cathodic Protection 1 Rotary Type of Grout <br /> Disposal f Other Other Information <br /> Geophysical t Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor, <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT. / / State Work Done <br /> PUMP -.REPAIR: X-7 State Work-Done j O [e� 6,( ,�,� <br /> AES-TRUCTION _OF WELL: Well Diameter Approximate Depth ' <br /> Describe Material and Procedure <br /> I hereby agree to comply withxall laws and regulations of the San Joaquin Local Health i.strict <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 AROUTING AND A FINAL INSPECTION. <br /> SIGNED. du) TITLE <br /> (I)RAW(I)RAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> DEPARTMENT�USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ;11 ` 7­1e� DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAM III . INAL IN9P9CTIQ <br /> INSPECTION BY DATE INSPECTION BVI DATE /I az <br /> E <br /> 1177 2M <br /> H X426 Rev. <br />