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jQY f �2 r /f <br /> I f! ��I�Jf// SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOEiOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> e 4 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 L 3-7 <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 /> i F <br /> 3 <br /> JOB ADDRESS/LOCATIONQirr—C CENSUS TRACT <br /> Owner c s Name -f Phone <br /> Address ' City <br /> Contractor's Name License #74"Z Phonee �5 7 <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN /? RECONDITION /7 DESTRUCTION <br /> PUMP INST LATION / / PUMP REPAIR /7 PUMP REPLACEMENT '/-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK Z,()U SEWER LINES PIT PRIVY i <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. a£ Well Casing x <br /> s Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic- Protection ^,^x Rotary Type of Grout <br /> Disposal , _ i Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION; Contractor 3 <br /> Type of Pump H.P. } <br /> _ i <br /> PUMP REPLACEMENT: / / State Work Done71 <br /> PUMP 'REPAIR: <br /> /7 State Work Done _ <br /> � _ <br /> pES-TRUCTION OF WELL: Well Diameter - Approximate Depth ; <br /> . Describe Material and Procedure I .� <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 anew'-well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the Well and _notifyIthem before putting.thewell 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 AN A FINAL INSPECTIOI3 -- <br /> SIGNED TITLE <br /> 4 <br /> "' (DRAW PLOT PLAN ON REVERSE SIDE <br /> T _ R DEPPaTMENT USE ONLY <br /> PHASE I . <br /> APPLICATION ACCEP BY �SCJMlp% DATE 7- z3 7� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIONPRASE III/FINAL INSPECTION <br /> INSPECTION BY DATE -/2 , n INSPECTION BY f"�'� DATE I <br /> k <br /> i E H 1426 Rev. 1-74 _ 1-74 2M <br />