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1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT - ---�- <br /> FOR USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP .PERMIT Permit No. Tall� <br /> THIS PERMIT EXPIRES- 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete• ln 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 /> JOB ADDRESS/LOCATION F1_00 LI vjoly_ 40 CENSUS TRACT <br /> Owner's Name ' <br /> Phone <br /> 9 <br /> Address wao�Y<vu City <br /> Contractor's Name t.0 Ki• "-License # Phone <br /> TYPE OF WORK (Check): NEW WELL/_7 DEEPEN/ 7 RECONDITION /_7 DESTRUCTION /_ t <br /> PUMP INSTALLATION / / PUMP REPAIR ` PUMP REPLACEMENT /7 R <br /> Other <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 Cas:Lng <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 T Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor - <br /> Type yP Pump ... a. H.P. /-4 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP '.REPAIR: State Work Done e. ✓p Ze <br /> ES•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.kng an ief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO TING AND A FINAL INSPECT . <br /> SIGNED <br /> (DRAWePLZ PLAN ON REVEE DE <br /> PHASE I <br /> 40.1 Pffir DEPARTMENT USE ONLY <br /> ` <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION "PHASEFIN INSPECTION <br /> INSPECTION BY DATE INSPECTION- BY DATE <br /> 1 E H 1426 Rev. 1-74 _� <br /> ,�4 2M <br />