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-- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FgArOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /«-7S­ <br /> S.7- "! (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. s pipplic i is de in compliance with San Joaquin <br /> County Ordinance No. 1862 Ru a n MI .Joa u n Local Health District. <br /> JOB ADDRESS/LOCATI rz (_�47,l <br /> v CEN5U5 TRACT C)tq-2-&O-ss <br /> Owner's Nam Phone <br /> Address City ZmjtSA7e4fW <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check): NEW WELL /? DEEPEN /_7 RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR /_7 PUMP REPLACEMENT /-7 <br /> Other /__7 <br /> r" <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 Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled ., Dia. of Well Casing <br /> Domestic/public Driven ' Gauge of Casing <br /> Irrigation Gravel Pack Depth of-Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information }� <br /> Geophysical Surface Seal Installed BX: <br /> PUMP INSTALLATION: Contractor v3 <br /> Type of Pump H.P. 1' <br /> PUMP REPLACEMENT: /7 State Work Doane <br /> PUMP :REPAIR: /_7 State Work Done <br /> ES•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Mat rial ond roc dura <br /> '_ <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of Cali ornia 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 <br /> WELL bRILLER RIEPOR the well and notify them before putting the. well in use.. The above <br /> informatio i true o tth best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G - FINAL INSP CTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVRRSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DAT <br /> ADDITIONAL COMMENTS: /Jt <br /> PHASE II GROU INSPECTION PHASE :RI/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE / <br /> E H 1426 Rev. 1-74 1-74 2M <br /> J <br />