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�x <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE•;"OF'RICE USE: go 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;s_�6to <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to constract � <br /> and/or install the work herein described. This application is made in compliance with San Joaqu n <br /> County Ordinance No. 1862 and the Rules and Regulations of the San 'Joaquin Local Health District. ' <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name PhonB - "- ` <br /> jag <br /> Address : ' , •� <br /> / City c <br /> Contractor's Name - = 410iicense # Phone <br /> TYPE'OF WORK (Check): NEW WELL "/ILS DEEPEN •/? RECONDITION %f DESTRUCTION;.f7 <br /> AL <br /> PUMP INSTLATION/ / PUMP REPAIR/_7 PUMP REPLACEMENT— <br /> Other / / .. . . . . . <br /> DISTANCE TO NEAREST: SEPTIC TANKfes' SEWER LINES FIT PRIVY i <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 /> �c Industrial Cable Tool Dia. of Well Excavation <br /> '• Domestic/private Drilled .. •Dia. ofWe1I Caging - - <br /> ✓� Domestic/publkd�" Gt=. <br /> Ariven Gauge-of-Casing <br /> Irrigation Gravel. Pack --Depth of Grout Seal o <br /> Cathodic Protection Rotary Type of GroutN .Tt-:_ <br /> Disposal Other _ Other Informatieg <br /> on _� Q <br /> Geophysical �� Surface Seal Installed B s <br /> PUMP INSTALLATION: Contractor <br /> "- BR A <br /> Type of PumpH.P. �. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP 'REPAIR: /7 State Work Done <br /> DESTRUCTION OF WELL Well Diameter f� <br /> 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. FWithin,FIFTEEN DA S A . <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..knowledge •and belief: I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING <br /> SIGNED AND 'iNAL INSPECTION. <br /> 'e' <br /> TITLE <br /> DRAW PLOT PLAN ON REVERSE _S1 <br /> PHASE I <br /> FOR DEPARTMENT .USE ONLY <br /> - <br /> APPLICATION ACCEPTED BY } DATE ;7;7F <br /> ADDITIONAL COMMENTS <br /> z PHASE II OUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION`BY DATE -- INSPECTION BY DATE <br /> E H 1426 <br /> Rev. 1-74 <br />