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_ ,;10 <br /> O S JOAQUIN LOCAL HEALTH DISTRICT <br /> 7Gfi OFFICE USE: v 1601-r. Hazelton Ave. , Stockton, Cali'r. <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 Issued <br /> (Complete In Triplicate) <br /> )plication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> ad/or install the work herein described. This application is made in compliance with San Joaquin <br /> Runty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health Di <br /> strict. <br /> JB ADDRESS/LOCATION l�JQs l• �N CENSUS TRACT s��-Jif <br /> aver's Name f�y/� 171 1 /V Phone k-� ��.�� <br /> 1dress �i� �ca� 4 +�� G[' ��� City <br /> antractor's Name License #,��Phone <br /> YPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION /_/ DESTRUCTION /_7 <br /> � <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT /_7 <br /> Other <br /> ISTANCE 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 /> 'UMP INSTALLATION: Contractor <br /> Type of Pump K.P. <br /> 'UMP REPLACEMENT: / / State Work Done <br /> 'UMP '.REPAIR: / State Work one Q- x-"42 <br /> �ES•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> ind 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 /> 4ELL 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 FORA GROUT INSPECTION <br /> 'RIOR TO GRO,KING AND AFNAI INSPECTION. <br /> SIGNED r��,/j., o� TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FO DEP NT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEP DATE <br /> ADDITIONAL COMMENTS <br /> -----T-' <br /> PHASE II GROUT INSPECTION P I F INSPECTION L <br /> INSPECTION BY ATE IN4SPEC ON BY TE -Z3- <br /> E H 1426 Rev. 1-74 1-74 2M <br />