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SAN UIN LOCAL L, <br /> i FOF�, FFICE USE: � C � HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> =� <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued <br /> A (Complete In Triplicate) <br /> Application'is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or ingtall the work herein described. This application is made -in compliance with San Joaqui <br /> flCounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB .ADDRESS/LOCATION �7 ��v <br /> Cez `� CENSUS TRACT <br /> Owner's Name cc i' , Phone <br /> Address <br /> '� - city. . <br /> Contractor's Name p� � , , <br /> License # J k1 Phone <br /> TYPE OF WORK (Check) ; NEW WELL /? DEEPEN -/7RECANDITION f7 DESTRUCTION f7 <br /> PUMP INSTALLATION/� PUMp REPAIR PUMP REPLACEMENT % f <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 V' <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge f Casing Q <br /> Irrigation Gravel..Pack- Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical. <br /> Surface -Seal Installed B <br /> + sPUMP INSTALLATION: Contractor <br /> Type-.of--Pump w. ;�" .� _ H.P. <br /> j PUMP REPLACEMENT: /_/ State Work Done' <br /> PUMP 'REPAIR: State Work Done Ca lu�r <br /> f <br /> DESTRUCTION OF WELL: Well. Diameter ' <br /> � zDescribe Material and Procedure Approximate Depth <br /> I hereby agree to comply with all laws' and regulations of the San Joaquin Local Health District <br /> end the State of California pertaining to or regulating weir'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 /> i inforuiation is true to. the,best .of my.knowledge-and belief. I WILL CALL -FOR 'A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL, INSpE 0 . <br /> SIGNED c, TITLE ?r--,Ir. <br /> D PLOT PLAN ON FRSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLI`CATION' ACCEPTED BY - DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPE ION 'PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ��..�.� DATE <br /> _E H 1426Rev. 1--74 <br />