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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 'OR�FOFFICE USE: 1601 E. Hazelton .Ave.''', `Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WtLL'CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 'l ,YEAR FROM DATE ISSUED Date Issued a 7 <br /> f f - - Com lete. In Tr <br /> � � Triplicate) <br /> licAte) <br /> � P <br /> Application is hereb made to the San Joa uin Local Hoa <br /> Y q .. 1th 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 /> LjCENSUS TRACT <br />' Owner°s Name <br /> Phone <br /> Address'-- - (�., �. �.. .. :: City <br /> 126 t, <br /> Contractor's Name d 06 I (2, , License # Phone <br /> TYPE OF WORK (Check): NEW WELL /? f <br /> DEEPEN /_7 RECONDITION /_7 DESTRUCTION / <br /> PUMP INSTALLATION / PUMA REPAIR /_7PUMP REPLACEMENT /_7 <br /> Others / / — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> k SEWAGEIDISPOSAL 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 r Dia._of. Well. Casing (� <br /> . f. _11 <br /> Domestic/public { Driven Gauge of Casing - <br /> _ ' Irrigation ji Gravel Pack Depth of Grout Seal <br /> - Cathodic Protection Rotary Type of Grout <br /> Disposal ! Other Other Information <br /> Geophysical { Surface Seal. Installed Bv:_, <br /> P +' <br /> UMP INSTALLATION. Contractors ,Q �o <br /> It- <br /> Type !of Pump i P �:n �...,.... H P. 75 <br /> PUMP REPLACEMENT: / / !State Work Done ! <br /> k — <br /> PUMP"REPAIR: /? !State Work Done <br /> I <br /> ES;TRUCTION OF WELL: WellrDiameter 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-beet-of- my knowledge and belief, I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL- INSPECTION. <br /> SIGNED ;t TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE�` <br /> I PHASE I . �' , l <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE 3 ?1 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION I AL MSPECTION <br /> INSPECTION BY DATE INSPECTION BY ATE <br /> E H 1426 Rev. 1-74 1-74 2M <br />