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�j+J{ SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFIQE USE: " `�1o01 E. Hazelton Ave. , Stockton, Calif. <br /> f►�/ Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�_ S9 ALJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued =2�­�g <br /> (Complete In Triplicate) <br /> Application is hereby 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 Joaquin <br /> County Ordinance No. 1862 and the Rules and. gulations of the San Joaquin Local Health `District. <br /> C <br /> JOB ADDRESS/LOC N CENSUS TRACT <br /> OA <br /> Owner's NameS Phone <br /> Address City <br /> Contractor's Name ense # ho T`b <br /> TYPE OF WORK (Check) : - .,NEW -WELL./ DEEPEN.'/ / -RECONDITION. / j -DESTRUCTION /-7 PUMP INSTALLATION /� PUMP REPAIR / / PUMP REPLACEMENT /� <br /> / <br /> Others <br /> DISTANCE TO NEAREST: 1 SEPTIC TANK SWER.LINE� PIT PRIVY <br /> SEWAGE DIS O FIELD <br /> ICETS OOL/SEEPAGE PIT <br /> AL OTHER <br /> PROPERTY LINE - PRIVA E DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF LL R CONSTRUCTION SPECIF A ONS 1- <br /> jAdustrial VCable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven ,� Gauge of Casing <br /> �ri-gation -,Gravel Pack Depth of Grout .Seal <br /> CathodicProtection Rotary ` Type of Grout H <br /> Disposal, 1 Other, Other Information ' <br /> Geophysical'' . j. Surface Seal Installed By: <br /> r <br /> PUMP INSTALLATION: _iContractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work..Done <br /> PUMP .REPAIR: Ll State Work Done <br /> DESTRUCTION OF WELL: Well -Diameter Approximate Depth_ <br /> _Describe Material and Procedure <br /> I hereb'y ,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 true o the b of4 knowledge and belief. I WILL C L FOR A GROUT INSPECTION <br /> PRIOR TO GR G. 6, A FIN NSP ON'. <br /> SIGNEDTITLE <br /> „ D T PLAN ON RE ERSE SlijLj <br /> A <br /> FOR DEPARTMENT USE ONLY r <br /> PHASE I p74 <br /> APPLICATION ACCEPTED BYDATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTI PHASE III'/ INAL INSPECT N ,/ <br /> INSPECTION BY DATEdq Y INSPECTION -BY DATE ` / 'dd <br /> E H 1426 , Rev. 1-74 <br />