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JOAQUIN LOCAL HEALTH DISTRICT ' <br /> � <br /> r FOR OFFICE USE: 160(). Hazelton Ave. , Stockton, Cal <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED-'� {{DLLL��JJJate Issued <br /> (Complete In Triplicate) <br /> Application is hereby madeJto 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 Joaquir <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> l �, <br /> JOB ADDRESS/LOCATION T� CENSUS TRACT <br /> Owner's Name . 0 1 .� / Phone <br /> Address City � ic: `tanJ <br /> Contr'actor's Name/��.�� `j'/,�:„ j , // /�a License #�5'?2 Phone <br /> TYPE OF WORK (Check) : NEW WELL�/)(f DEEPEN_/ / RECONDITIO_N_/ / DESTRUCTION /—] <br /> PUMP INSTALLATION / / PUi1P REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY _ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL -T.- PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL - CONSTRUCTION SPECIFICATIONS --- <br /> Industrial Cable Tool Dia. of Well Excavation __--- <br /> X' Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing _ /60, <br /> Irrigation Gravel Pack Depth of Grout Sear <br /> Cathodic Protection Rotary Type of Grout & eAt � <br /> Disposal Other Other Information _ - <br /> Geophysical - - Surface Seal Installed ByJn,l/fn <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done t <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter _ Approximate Depth <br /> I ' 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 /> C WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> 1 information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAILZINSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ^f .� F� .,, . '; DATE ` <br /> ADDITIONAL COMMENTS: <br /> PHASE 11 GROUT INSPETIP4A$A.I%PVFINAL INSPECTION <br /> INSPECTION BY -1 DATE INSPECTION BY DATE 1 T4 <br /> -"� <br /> 6177 2M <br /> E H 1426 Rev- 1-74 <br /> _ <br />