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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORrOFFICE USE: 1601 E: Hazelton Ave. , Stockton, Calif. C(j <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �Sy 34 941 <br /> THIS PERMIT EXPIRES 3'-YEAR FROM .DATE ISSUED Date issued 7- -7.5r <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> Jpt ADDRESS/LOCATION 4 <br /> CENSUS TRACT <br /> Owner' r s Name Phone --, � <br /> Address <br /> Cit <br /> Contractor s Name v s- _ License 1j;4g-�?/phone <br /> f <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/7 RECONDITION /7 DESTRUCTION <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT <br /> Other 1 / � <br /> f 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 <br /> Cable Tool <br /> ----,r Dia. of Well Excavation Q:. <br /> 4 Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> 11 <br /> Irrigation Gravel Pack Depth of Grout Seal ' <br /> Cathodic Protection Rotary ` Type of Grout 10—n-""; <br /> Disposal Other Other Information "" <br /> Geophysical <br /> Surface Seal .Installed By: ; <br /> PW INSTALLATION: Contractor <br /> T <br /> ype of Pump H.P. j <br /> PU `REPLACEMENT: / / State Work Done ` <br /> PUMP '.REPAIR: <br /> L-7 State Work Done <br /> ES;TRUCTION OF WELL: Well Diameter <br /> 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 f <br /> after completion of my work on a new well, I will furnish the San Joaquin Loedl`Health-District a <br /> WELL DRILLERS REPORT of the well and notify them before putting. the..well in-use.. The above <br /> informatio a to th of- my.knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIO G A F AL SP N. r <br /> SIG TITLBC�- � <br /> (DRAW PLOT PLAN ON REVERSE SIDS V " - <br /> FOR DEPARTMENT USE ONLY E <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE <br /> P UT INSPECTIO <br /> P%pPHA I AL SPECTIO <br /> INSPECTION BY ATE INSPECTION B ATE <br /> � <br /> E. <br /> H 3426 <br /> Rev. 1-74 <br /> 1-74 2M <br />