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SAN JOAQUIN LOCAL 'HEALTH DISTRICT <br /> FOE OFFICE USE: !l1' 1601 E. Hazelton -Ave. , Stockton, Calif. <br /> Telephone: .(209)- 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 1 <br /> THIS PERMIT EXPIRES' l YEAR FROM DATE ISSUED Date Issued <br /> ... (Complete In Triplicate) ppb ^q�© <br /> Application is hereby made to the San Joaquin Local-fkalth District for a perMit to construct <br /> end/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 He th District. <br /> r <br /> JOB ADDRESS/LOCATION I4oZIA <br /> M <br /> J`• Jl CENSUS TRA <br /> Owner's NameZ Phone <br /> Address 712 <br /> F City <br /> Contractor's Name <br /> h License # Phone�� <br /> I i <br /> TYPE OF WORKNEW:Check) I <br /> ( WELL /� DEEPEN RECONDITION /? DESTRUCTION � iv <br /> _ rt <br /> PUMP INSTALLATION Tv <br /> REPAIR /—/ PUMP REPLACEMENT � � q <br /> 0the r�f --'G5r U1 U <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 i <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial I Cable Tool Dia, of Well Excavation �. <br /> Domestic/private Drilled Dia. of Well Casing { <br /> Domestic/public � ` . 11 Driven Gauge of Casing <br /> Irrigation F Gravel Pack Depth of Grout Seal <br /> ' Cathodic Protection. + Rotary Type of Grout <br /> Disposal t Other Other Information <br /> Geophysical - Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor _ -A � <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /_7 State Work Done ry ; <br /> PUMP :1tEPAIR: 7 <br /> State•Work..Done <br /> ES;TRUCTION OF WELL: Well Diameter Approximate De th <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 TOG UT G !! <br /> FINAL INSPECTION. <br /> SIGNED TITLE <br /> t (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE - �' �" <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION- BY DATE 7L---7o <br /> ^E H 1426 Rev. 1-74 T Cff 3� 4 <br />�- 1-�•dr��t # <br />