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✓/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE; 1601 E. Hazelton.Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> 4 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,ZF_Z S/3 <br /> t <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 and the Rules and Regulations of the San Joaquin Local Health District. <br /> s JOB ADDRESS/LOCATION 13 SUS TRACT <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name Licenseon <br /> 9p1_1 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN-/ / RECONDITION/ / - -DESTRUCTION /_7 <br /> PUMP INS ALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> k DISTANCE TO NEAREST: SEPTIC, TANKSEWER LINE§,jAft0 PIT PRIVY <br /> SEWAGEi;DTSP SAL FIELD C SSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC: DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 11 Cable Tool Dia, of Well Excavation <br /> Domestic/private I -leDrilled Dia, of Well Casing , <br /> _�°Domestic/publics Driven Gauge of Casing <br /> IrrigationGravel Pack Depth of Grout Seal <br /> Cathodic,Protection V Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical y Surface Seal Installed By: <br /> n f <br /> PUMP INSTALLATION: Contractor <br /> Type o Pump H.P. <br /> PUMP REPLACEMENT: <br /> / / State ,Work Done <br /> PUMPREPAIR: <br /> R_ / / 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 a <br /> WELL DRILLERS REPORT of the well and notify them before putting. the well in use.. The .above r <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. 7 <br /> SIGNED.. L TITLE <br /> ~ (DRAW PLOT PLAN ON REVERSE SID ' <br /> r <br /> r <br /> FOR DEPARTMENT USE ONLY _ <br /> PHASE I , <br /> APPLICATION ACCEPTED BY DATE �?rt)- 7 <br /> ADDITIONAL COMMENTS: t� € <br /> PHASE TI GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION SY DATE INSPECTION BY DATE A9-7 <br /> E H 1426 Rev. . 1-74 'r 5! of%72M <br />