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SAN JOAQUIN LOCAL HE <br /> F - <br /> FOEOFVICLUSE: ALTH DISTRICT <br /> I601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone:Tele <br /> P (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT 'EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued <br /> (Complete In: Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> rind/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 ADDRESS/LOCATION 3 J� [4 v m n y CENSUS TRACT <br />� Owner's Name <br /> a' Phone <br /> Address <br /> rtei16 ol <br /> ' city , S <br /> c4 C1 <br /> Contractor's. Name , <br /> License '�/J��, 7one 241 <br /> TYPE OF WORK (Check): NEW WELL L__7 DEEPEN 17 RECONDTTSON /? DESTRUCTION f7 <br /> PUMP INSTALLATION / / PUMP REPAIR/-7PUMP REPLACEMENT .jgr <br /> Other /% <br /> i - <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER Y.TNES PTT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> PROPERTY LINE - PRIVATE DOMESTIC WE PUBLIC DOMESTIC OTHER <br /> ELL <br /> TNTENDED. USE TYPE OF WELL <br /> Industrial CONSTRUCTxQN SPECIFICATIONS y� <br /> Cable Taol Dia. of Well}C Excavation ..Domestic/private Drilled Dia. of We1I Casing <br /> cli <br /> Domestic/public Driven - Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal ' <br /> Cathodic Pr'otec'tion Rotary Typeyof Grout <br /> _._Disposal-. .. Other <br /> Geophysical Other Information <br /> Surface Seal Installed 'B <br /> PUMP INSTALLATION: <br /> Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP '.REPATR: <br /> _/ 7 State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> } <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. knowledg and belief. <br /> PRIOR TOG I WILL CALL FOR A GROUT INSPECTION <br /> U ING AND A t'TNAL INSPE IO . <br /> SIGNED ; <br /> TITLE 2 <br /> (D LOT PLAN ON ERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> Z 'PLICATION' ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE l <br /> PHASE II GROUT SPECTION <br /> INSPECTION BY PHASE IIT ]FINAL INSPECTION <br /> DATE iNSPEGTION BY <br /> DATE �zy:?A <br /> E H 1426 Rev. 1-74 - J <br />