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e <br /> �+ SAN JOAQUIN LOCAL-�-HEALTH DISTRICT <br /> FOR OFFICE USE: 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209)° 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION?rOR-PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED. Date Issued <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 andthe. Rules and Regulations of, the Sari Joaquin Local Health District. <br /> S`� ._3'�.:_. ccs rrz�-`�, -I <br /> J©B ABbktss% otftI0N Tt7j- D CENSUS TRACT <br /> Owner's Name � Phoner-0 - <br /> Address City -0 <br /> Contractor's Name t -U �S (� 2��2 License �� Phoners9-3v�� <br /> .TYPE OF WORK (Check) : NEW WELL/ / DEEPEN _/ RECONDITION / DESTRUCTION /-7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT / <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK fc-"jSEWER LINES1 qQffPIT PRIVY <br /> SEWAGE DISPOSAL FIELD C SSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> a INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS +" <br /> y Industrial Cable Tool. Dia. of Well Excavation _ <br /> t <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 /> f PUMP INSTALLATION: Contractor V C��--- F <br /> Type of Pump 1� L3 . H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP -.REPAIR: / / State Work Done <br /> DESTRUCTION 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 <br /> WELL DRILLERS REPORT of the well and geotify them before putting the well in use. The above <br /> informationAs true to the be t of m ,knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G q' ING A FINA ON. <br /> SIGNED r. TITLE <br /> 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 INSPECTRN SE I FINAL INSPEC IO*--? <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 6, 77 2M <br /> E H 1426 Rev. - 1-74 <br />