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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 0--B;,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �lrJ <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Re ulations of the San Joaquin Local Health District. <br /> / 4'3 `EO A/ <br /> JOB ADDRESS/LOCATION CENSUS TRACT ODS- 040-Ig <br /> Owner's,Name <br /> Address . 7 4C// ( o � City <br /> 1AY3 z& 7 Y5-f3 <br /> Contractor's Name License # . Phone u 7 <br /> TYPE OF 'WORK (Check): NEW WELL / DEEPEN/_7 RECONDITION /—f DESTRUCTION /7 <br /> PUMP INSTALLATION J / PUMP REPAIR -/ PUMP REPLACEMENT 17 "-N <br /> Other 1_7 r.p <br /> C4 <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 i_--eat'le Tool Dia. of Well Excavation -,7-- <br /> �Bvisestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing /2 <br /> Irrigation Gravel Pack Depth of Grout Seal _ 'b <br /> Cathodic Protection Rotary Type of GroutiJ <br /> Disposal Other Other Information " <br /> Geophysical. Surface Seal Installed By: <br /> PUMP INSTALLATION: Contracto . <br /> Type of Pump H.P. . <br /> PUMP REPLACEMENT: • / / State Work Done <br /> if <br /> PUMP '.REPAIR: / / State Work Done ' <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure z <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 my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO ';GR TING AND NAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> �Q <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS <br /> PHASE Ti GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. W75 2M <br />_ 1-74 <br />