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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR•,OFFICE USE: 1601°E. Hazelton Ave. , Stockton; Calif. ��O� 1 <br /> Telephone: (204) 466-6781 G� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT, Permit No. � <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 ty, the /,,fit► gu # Coz�g,of the San Joaquin Local health District. <br /> JOB ADDRESS/LOCATION�;%jJ Cr/ RACT b 19 <br /> Owneres Name �' Phone <br /> Address City �la7 <br /> Contractor's Name <br /> Avo License # Phone <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN /_7 RECONDITIONLy DESTRUCTION %j <br /> PUMP INSTALLATION PUMP REPAIR / REPLACEMENT %f <br /> 0th T /% <br /> aat C�h <br /> DISTANCE TO NEAREST: SEP IC 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 By: <br /> PUMP INSTALLATION: Contractor <br /> .,,.._ Tape of Pump <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: /7 State Work Done <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 ZR' <br /> is pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completionk on a new well, I will furnish the San Joaquin Local Health District <br /> WELL DRILL e well and notify them before putting.the. well in .use.. The above <br /> informat n t -best of. my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GIMPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE Y FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -/� DATE !/4z=/ <br /> ADDITIONAL COMMENTS: ,( 7t' y <br /> PHASE IIG UT INSPECTION PHASE TII4FINAL INSPECTION <br /> INSPECTION BY A11.4- DATE INSPECTION BY DATE <br /> t <br /> ' E H 1426 Rev. 1-74 1-74 2M <br /> 1 <br />