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\A <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOh.*OFFICE USE: r. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 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/a <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 /> JOB ADDRESS/LOCATION33 GC/l�Lt��-T/d CENSUS TRACT <br /> Owned s Name. . Phone <br /> Address �z City < � <br /> Contractor's Name License #,7,v_v/;7 hone <br /> i <br /> TYPE OF'WORK (Check) : NEW WELL DEEPEN /_/ RECONDITION /-7, -DESTRUCTION /_ ? <br /> ? PUMP INSTALLATION � PUMP REPAIR / / PUMP REPLACEMENT /7 F <br /> ` <br /> DISTANCE TO NEAREST: SEPTIC TANK 0 SEWER LINES PIT PRIVY <br /> 3 SEWAGE DISPOSALFIELD CESSPOOL/SEEPAGE PIT : OTHER <br /> PROPERTY LINED RIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL kk <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 4 <br /> Industrial k Cable Tool Dia. of Well Excavation _ f© {{ <br /> Domestic/private Drilled Dia. of Well Casing (� <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal © p _ <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> ` "Geophysical <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contrac.�or <br /> Type oi- Pump - �'U /tea i H.P. / s <br /> PUMP REPLACEMENT: Y' 7n " <br /> / / State Work Done <br /> PUMP .REPAIR: /7 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 DAIS <br /> after completion of my ra on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT f the well and notify them before putting the well in use.. The above ' <br /> information is tru to the best .of my k owledge and belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO GROU NAL IN P8C N.• <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) oil <br /> ` f F <br /> PHASE i FOR DEPARTMENT USE ONLY <br /> * ^' <br /> APPLICATION ACCEPTED BYN _� �""�„"' -- - - — DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H '1426 Rev. 1-74 �° •" 1777 .. 2M <br />