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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: ' 1601 E. Hazelton Ave. , ,Stockton, Calif. 5 <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 IssueddAN-111V9 <br /> (Complete In Triplicate) <br /> Application is Aereby 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 Jo4uin <br /> County Ordinance No. 1862 and the Rules and Regulations of7t e San Joaquin Local Health District. <br /> JOB ADDRE S'/LOCA- 071 <br /> ANT <br /> S CENSUS TRACT <br /> Owner's .Name e Ic Phone , <br /> Address <br /> ntnj a- vd City ,T <br /> Contractor's Name ; 111'r7n C License # Phone <br /> i Al-YPE OF WORK (Check) : NEW WELL QomDEEPEN /% RECONDITION / ./ DESTRUCTION /- <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> j 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 <br /> t � <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal 5 0S <br /> Cathodic Protection - Rotary Type of Grout ' <br /> Disposal Other Other Information <br /> Geophysical Surface Seal. Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP`:-REPAIR• -/ /-- -— , <br /> State Work`Done - <br /> DESJRUCTION .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 istrict <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 the well and otify them before putting the mell in use. The above <br /> information i.s�tru the best o my wledge and belief, I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G D A F SP <br /> i SIGNED TITLE <br /> (DRAW PLOT PLAN ON. REVERSE SIDE) ' <br /> - FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCJ <br /> CEPTED BY DATEI <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BYDATE �.- .3 �� INSPECTION BY � DATE A -3 7rP' <br />' r <br /> _E H 1426 Rev; 1-74 T 1117 2H <br />