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{ <br /> SAN JOAQUIN LOCAL ,HEALTH DISTRICT <br /> 7F_0R* OFFICE USE: 1601 E. Hazelton Ave., -Stockton, Calif. <br /> ` <br /> Telephone; . (209) 466--678I <br /> A/1 :. :.;.F e:e rALDALICAT-.ON FOR.WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM--DATE ISSUED x 6 - Date Issued�s <br /> "-a .(Complete In"Triplicate) <br /> Application is hereby made to the Sen 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 th u tsand Regulation f. the San Joaquin Local Health District. <br /> !. � <br /> 41 <br /> JOB ADDRESS/LOCATION • ' A US TRACT <br /> Owner's Name K Phone <br /> Address ' �ry / � u _ City <br /> 4 <br /> Contractor's Name License hone <br /> TYPE OF WORK (Check): NEW WELL/^DEEPEN. /-7 RECONDITION 17 ' DESTRUCTION /-7 <br /> PUMP INSTALLATION / $UMP REPAIR J� PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK /df® SEWER LINES : PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/.SEEPAGE PIT: OTHER <br /> 'PROPERTY LINE -- PRIVATE DOMESTIC WELL` PUBLIC DOMESTIC WELL L <br /> INTENDED USr� TYPE OF WELL CONSTRUCTION SPECIFICATIONS .0 <br /> Industrial able Tool Dia. of Well Excavation <br /> _-k,ewDomestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing W <br /> Irrigation Gravel Pack Depth of Grout Seal . "O <br /> Cathodic Protection Rotary" Type of Grout" _ <br /> Disposal 'Other Other Information <br /> Geophysical Surface Seal Installed B <br /> 00* F <br /> PUMP INSTALLATION: . Contractor { <br /> Type of Pump H.P- <br /> PUMP REPLACEMENT: /_7 State Work Done <br /> PUMP `.REPAIR-.,_ , /77 State Work Done; _. .. <br /> E&TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> f <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 oii 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-beat of my ,knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUjj4G AED A FINAL ECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE S'IDE)� - <br /> ' FOR DEPARTMENT USTONLY <br /> PHASE , <br /> APPLICATION ACCEPTED BYs DATE �T S <br /> ADDITIONAL COMMENTS: <br /> .PHASE'II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION- BYDATE <br /> _E,. H 1426 r. Rev. 1-74 <br />-t 1-74 Atom <br />