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{' 1 JOAQUIN LOCAL HEALTH DISTRICT <br /> k0&iQFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. .234,,' r <br /> THIS PERMIT EXPIRES 1 YEAR FROM. DATE ISSUED Date Issued7,!, s <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 /> JOB ADDRESS/LOCATION ! <br /> ��1=----�-1�a.�tl'��r.�_�f�,dll1����rr �j( ENSUS TRACT <br /> [homer's Name , Phone <br /> AddressI city <br /> Contractor's Name License # 1,2k7.2� Phone .9B 7.)W <br /> TYPE OF WORK {Check}: NEW WELL/X7 DEEPEN '/__7 RECONDITION /_7 DESTRUCTION f_7 <br /> PUMP INST LATION / / PUMP REPAIR j /PUMP REPLACEMENT f7 <br /> Other <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER,LINES PIT PRIVY t <br /> SEWAGE DISPOSAL FIELD ', <br /> .1 <br /> SEWAGE PIT OTHER 0 <br /> PROPERTY LINE• - PRIVATE DOMESTIC WELL "PUBLIC DOMESTIC"WELT:" Q , <br /> INTENDED USE TYPE -OF• WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ^ Cable fool Dia. 'of Well Excavation t'4 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public .; Driven Gauge,of Casing <br /> f _ Irrigation Gravel Pack Depth ,of Grout. Seal V <br /> E Cathodic Protection Rotary *Type of Grout <br /> Disposal Other:• .,,.Other Information <br /> Geophysical . Surgace Seal Installed By: <br /> PUMP INSTALLATION: Contractor , - N <br /> Type of Pump _ H.P. <br /> a <br /> PUMP REPLACEMENT: / '/ State Work Done <br /> i <br /> PUMP-REPAIR•:, ,_ r / .. ---State.",Work:-Done.._.. � ...�:�.r-,.r-� - .��.- - -.4 <br /> ES•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 of myknowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. [ <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ' <br /> APPLICATION ACCEPTED BY <br /> DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIONPISA N INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY f.' ATE L <br /> E H 1426 . Rev. 1-74 � <br />