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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> v�;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif.. <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 Issued <br /> (Compete In Triplicate) <br /> 0Application is {hereby nide 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 .Regulations of the San -Joaquin Local Health District,. <br /> JOB ADDRESS/ A-ir- Ci3US TRACT <br /> Owner's Name <br /> Phone ' <br /> � 11 <br /> Address - Cit <br /> Y Contra-ctor s Name License ' Phone /� <br /> iN <br />--ftPE OVWORK (Check): NEW WELL . DEEPEN -/- RECONDITION /-7 DESTRUCTION /—f , <br /> PUMP INSTALLATION /V PUMP REPAIR /� PUMP REPLACEMENT <br /> Other /% T` if G <br /> DISTANCE TO NEAREST: SEPTIC TANK tJ {- SEWER LINES PIT PRIVY <br /> SEWAGE DISPOS;.,,.YIELD ­ CESSPOOL/SEEPAGE PIT .»s-- OTHER �- <br /> PROPERTY LINE' RIVATE DOMESTIC WELL'M9-PUBLIC DOMESTIC WELL <br /> INTENDED USE is -TYPE OF WELL CONSTRUCTION SPECIFICATIONS �- <br /> Industrial Gable Tool { Dia. of Well Excavation : �. C <br /> Domestic/private Domestic Drilled Dia. of Well. Casing S pig <br /> -_� <br /> /Public { Driven � Gauge of Casing iii .� <br /> Irrigation Gravel Pack'' Depth .of Grout Seal l i <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other-- , Other Information <br /> Geophysical Surface Seal Installed 'B t <br /> PUMP INSTALLATION: Contractorpy <br /> Type. .of.-Pump < H.P. " -- _ <br /> PUMP. REPLACEMENT: , E/ Stag Work Doe N <br /> NI <br /> PW REPAIR: /': State .Work Done <br /> DESTRUCTION OF WELL: Well, Diameter Approximate Depth ' <br /> Describe Material and Procedure i! <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. WithinFIFTEEN 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 my..knowled a and belief. I WILL CALL 'FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A 14NAL INSPECTION, <br /> SIGNED TITLE j <br /> I (DRAW PtOT PLAN ON REVERSE SI j� <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION' ACCEPTED BY <br /> �. ./ . ATE ./42- "7 P <br /> ADDITIONAL COMMENTS: i II <br /> PHAS II ROUT INSPECTIO PHASE I I F NAL iNSPE ON <br /> INSPECTION BY & DATE el7k INSPECTION BY DAT�/:I �96 7" <br /> E H-1426 -, . _Rev. 1-74. L/7c w- W <br />