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SAN JOAQUIN LOCAL HEALTH DISTRICT p <br /> FOR-.OFFICE USE 1601 E. Hazelton Ave. , .Stockton, Calif. _ r � <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 �l��rJ <br /> ' ,; � <br /> :. (Complete In Triplicate) <br /> Application is 4ereby mane to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described, his application is made in compliance with San Joaquin, <br /> County Ordinance No. 1862 and the. Rules degulations of the San. Joaquin Local Health District. <br /> l <br />'JOB ADDRESS�LOCATION ! 6 7 P s , <br /> i CENSUS TRACT <br /> r �y <br /> Owner's Name Phone <br /> �-} r <br /> Address d 4 .F ,._ <br /> Cit <br /> �a�+ 26fG g <br /> Contractor's Name - License l ' 'one <br /> TYPE OF WORK (Check) : NEW WELL /T DEEPEN '/�—/ RECONDITION / DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR /tom PUMP REPLACEMENT /7 <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 Casing 0 <br /> Domestic/public ,, .Driven Gauge of Casing �J+° <br /> Irrigation Gravel. Pack ' Depth of Grout Seal <br /> Cathodic Pratectionj Rotary Type of Grout <br /> Disposal Other Other Information ` <br /> Geophysical Surface Seal Installed By: <br /> P <br /> PUMP INSTALLATION: <br /> Contractor <br /> Type of Pump H.P. <br /> j! <br /> PUMP REPLACEMENT: /�/ State Work,Done <br /> PUMP ,.REPAIR: /Mate Work Don - <br /> DES-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 istr ' <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 s <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 knowledge and belief. I WILL CALL FOR A GROUT' INSPECTION <br />'RIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE '- <br /> v (DRAW PLOT PLAN ON REVERSE SIDE) - -"' <br /> .i FOR DEPARTMENT USE ONLY --- -* <br /> PHASE I <br /> ii <br /> PLICATION ACCEPTED .BY C/. DATE <br /> kDDITIONAL COMMENTS: s g <br /> PHASE II GROUT INSPECTION PHASE; Ill- F-INAL INSPECTION <br /> INSPECTION BY 0 DATE INSPECTION BY DATE <br /> E H, 1426 Revvz1-74 ! I./71 - 2K <br />