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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOV-. OFFICE USE: � 1601 E. Hazelton 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 Issued7(� <br /> (Complete In Triplicate) <br /> Application is hereby made i the San Joaquin Local Health District 0,%r a ��rn "o :onstruct <br /> and/or install the work here.n described. This apptuft <br /> nis made <br /> eSan Jin tomuin Local f Health San Josq�n <br /> County Ordinance No. 1862 and the Rules and Regulations <br /> JOB ADDRESS/LOCATION � • � CENSUS TRACT <br /> Phone <br /> Ouner's Name <br /> it <br /> /� % <br /> Address �7oil,F <br /> License � I hone 1 <br /> '• Contractor a Name �'V �L <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /7 RECONDITION /7 DESTRUCTION LI <br /> PUMP 7NSTALLATION i-7 -pumpREPAIR L-7 PUMP REPLAClO$N'C <br /> Other L� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY p <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRI•.ATE DOMESTIC WELL --- PUBLIC DOMESTIC WELL <br /> .'� INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> In ustrial ble Tool Dia. of Well Excavation <br /> ova alit/private Drilled Dia. of Well Casing f e <br /> Domestic/public Driven Gauge of Casing Z <br /> Irrigation Gravel Pack Depth of Grout Seal — <br /> Rotary <br /> Cathodic Protection Type of Grout 7 / �� <br /> Disposal Other Other Information <br /> Geophyeica]. f+_ce Seal Installed BY: <br /> PUMP INSTALLATION: Contractor k H.P. <br /> Type of Pump <br /> • M <br /> } PU?R REPLACEMENT: L/ State Work Done <br /> • State WorK Done <br /> PUMP REPAIR: L� <br /> ff DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> ts' Describe Material and Procedure f , <br /> ly <br /> with all laws and regulations of the San Joaquin Local Health District <br /> I hereby agree to comp <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 Joa�gilnin use.LocAl �Thehaboveriet a <br /> WELL DRILLERS REPORT of the well and notify <br /> knowledgemandbefore <br /> belief. I the WILL CALL FOR A GROUT INSPECTION <br /> ' information is true to the t o my <br /> knowledge <br /> PRIOR TO GR I A F IN ECThON. TITLE •----+•I <br /> SIGNED - y <br /> DRAW T PLAN ON EVERSE SI IJ <br /> R DEPARTMENT USE ONLY <br /> PHASE I DATE 1/ <br /> APPLICATICV ACCEPTED BY <br /> ADDITIONAL COMMHNTS: PHASE TI�&N <br /> PHASE II GROUT INSPECTION , I.JSPECTION BY �• �K__ <br /> INSPECTION BY DATE <br /> 3/76 2K <br /> E H 1426 Rev. 1-74 <br />