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JOAQUIN LOCAL HEALTH DISTRICT <br /> FOH OFFICE USE: 160 . Hazelton Ave. , Stockton, Calx.. '. <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUIP1U? PERMIT Permit No. %5 &4/�� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued / - Jy <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 and the Rules and Regulations of the San Joaquin Local Health District. <br /> 30B ADDRESS/LOCATION C!: ,/i��� /��9i_7 c CENSUS TRACT <br /> If r1 <br /> Owner's Name I'^ Tc'k r° s .�: "'` �c' sr?tCts hone <br /> Address /� Q /f� f'���r rxlf�.,� / City <br /> Contractor's Name /yi: License -.'Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION _ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR FUMP REPLACEMENT <br /> Other / / f, �� // / �e ...` <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 By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> 2ES-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 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 best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE-- <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY / DATE1 ' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IIVFINAI,71,NSPECTION _ <br /> INSPECTION BY DATE INSPECTION BY _ � � DATE 7S <br /> E H 1426 Rev. 1-74 1 '7 nit <br />