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SAN JOAfVIN LOCAL HEALTH DISTRICT <br /> FOT7:'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXP' <br /> I YEAR FROM DATE -ISSUED Daae Issued 3-� L'-7G <br /> F (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local health District fora permit to construct 1 <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 /> .TOB ADDRESS/LOCATION : M„n ,,,k CENSUS TRACT <br /> Owner's Name 133Phone , i <br /> Address <br /> Contractor's Name <br /> License # Phone <br /> TYPE-FTWORK (Check): - NEW WELL / 7 •DEEPEN ,/-7 RECONDITION /7 DESTRUCTION ,/7 i <br /> PUMP INSTALLATIONN_/ / PUMP REPAIR'o PUMP REPLACEMENT /7 4 <br /> Other <br /> r <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 /> Y <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industria. Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <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 Surface Seal Installed BY: <br />.PUMP INSTALLATION:- 'Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: / / state Work Done <br /> PUMP' REPAIR; / State Work Done _ <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth I <br /> Describe Material and Procedure E <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..knowledge and belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO GROUTTNG AND A ViNAL INSPECTION. 1 <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION'ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT I PECTION PHASE III Ii'INAL INSPECTION <br /> INSPECTION BY s DATE INSPECTION BY �s?, ( ; _ DATE z� <br /> AV <br /> E H71426 Rev. 1-74 h/75 2M <br />