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SAN JOAQUIN LOCAL HEALTH DISTRICT - <br /> FOR,OFFICE USE: VZ 160 . E. Hazel.iton.,A,ye. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2,6_,5-46&1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM' DATE ISSUED Date Issued ,��-7l <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 /> ,TOB ADDRESS/LOCATION fft)i) $ r SU T5 RACT <br /> Owner's Name Phone <br /> y <br /> rt <br /> Address a th City <br /> Contractor's Name Pa.AAA ILicense # Jo2t7,tV Phone Lz �I ) <br /> TYPE OF WORK (Check): NEW WELL/ ' DEEPEN -/_7 RECONDITION /7 j <br /> DESTRUCTION / <br /> '. PUMP INSTALLATION /—/ PUMP REPAIR 1-7—pump REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY t� I <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER r� <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL d ` <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Q <br /> Industrial Cable Tool Dia. of Well Excavation rr •• <br /> Domestic/private Drilled Dia. of Well Casing r ""�? <br /> ► Domestic/public Driven Gauge of-Casing r4�./fir \4 <br /> _ Irrigation Gravel Pack Depth of Grout Seal V <br /> 4 <br /> Cathodic Protection Rotary Type of Grout' i <br /> Disposal ' Other Other Information <br /> Geophysical �� Surface Seal" Installed By: <br /> PUMP INSTALLATIONS Contractor € <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: f_1 State Work Done ' <br />"-PUMP :REPAIR: /7 State Work Done <br /> E&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 Chet San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify ,them before puttingthe..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 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 DATE jp 7(0 <br /> ADDITIONAL COMMENTS: - - l <br /> PHASE II GROUT INSPECTION P E II FI AL INSPECTION <br /> INSPECTION BY DATE INSPECTION B DATE <br />'� y ^E H 1426 Rev. 1-74 1_7A Im <br />