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SAN JOAOIN LOCAL HEALTH DISTRICT <br /> FOR(OFFICE USE: 1601 E. Hazelton Ave. ,_Stockton, Calif. <br /> Telephone: (209),, 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �4t-niLA) <br /> Y <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 /> JOB VWKW S/LOCATION SUS TRACT <br /> Owner's Nam i Phone <br /> Address City , <br /> Contractor'a NameA0 � /- �}- �m <br /> 'License Phone <br /> TYPE OF WORK (Check): NEW WELL /7x" DEEPEN' /7, RECONDITION /-7 DESTRUCTION <br /> PUMP INSTALLATION 17PUMP REPAIR / / PUMP REPLACEMENT /—f <br /> . ' ¢ Other /-7 <br /> ,.DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES--.- PIT PRIVY <br /> SEWAGE DISPOSAL FIELDjQtp C SSPOOL/SEEPAGE PIT OTHER 'S <br /> PROPERTY LINE - PRIVATE DOMESTIC WEi.L 64"PUBLIC DOMESTIC WELL 2 <br /> ' INTENDED-USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> Industrial Cable Tool Dia. of Well Excavation <br />� — Domestic/private Drilled Dia. of Well Casing <br /> F Domestic/public Driven -� Gauge of Casing <br /> Irrigation , 1 Gravel Pack Depth of Grout Seal <br /> Cathodic Protection ' Rotary Type of Grout <br /> Disposal F Other Other Information <br /> y <br /> �} Geophysical Surface Seal Installed By: <br /> k rf <br /> PUMP. INSTALLATION:' Contractor - <br /> Type of Pump H.P. <br /> "PUMP -REPLACEMENT: / / State Work Done <br /> PUMP '.REPAIR: /7 State Work- Done <br /> ES-TRUCTION OF WELL: Well Diameter Z'Appr xim to Depth <br /> Descri a Material and Procedure 1 <br /> W . ry <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 regulat,ing .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 myknowledge and belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPE CTIO <br /> SIGNED <br /> TIE <br /> PLOT-PLAN ON REVERSE SIDE) <br /> OR DE TMENT USE ONLY <br /> PRASE I j <br /> APPLICATION ACCEPTED Y / - - Yom- - '°y' �' 6ATE <br /> ADDITIONAL COMMENTS: <br /> -PHASE II GROUT INSPECTION i PHASE IINSPECTI N <br /> INSPECTION BY .. DATE 4 INSPECTION. BY 04t= DATE <br />,} E H 1426 Rev. 1-74 '3 lt4cv 1-74V 1-74 2M <br />