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4 <br /> SAN JOAQUIN LOCAs, HEALTH DISTRICT <br /> .-FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.2r-70� <br /> t <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued .S � <br /> ° (Complete In Triplicate) <br /># <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or inst.a.11 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 /> 4 r� <br />' JOB ADDRESS/LOCATION 2 C9" t CENSUS TRACT ' <br /> I` Owner°s Name. Phone <br />' L F <br /> Address City <br /> Contractor's Name 01LicensCf2 Phon <br /> QTY OF WORK_(Check) EW WELL ./�__DEETEI -/<�,./j RECONDITION ./_/, DESTRUCTION <br /> PUMP INSTALLATION / MP`rREPAIR PUMP REPLACEI�IENT /_7 r <br />° Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK 4_SEWER LINES PIT PRIVY ..1 <br /> SEWAGE DISPOSAL FIELD E Q <br /> CESSPOOL/SEEPAGPIT OTHER <br /> PROPERTY LINE - PRIVATE- DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cab1:e_3Tool Dia, of Well Excavation <br />' _-BPOmestic/private Dri-Iled 4 Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation /2Gravel Pack Depth of Grout Seal u-I �j j <br /> Cathodic Protection 4----R-otary 0 Type of Grout i <br /> Disposal Ether Other'Information <br /> Geophysical _- Surface Seal Installed By: .� <br /> y <br /> PUMP INSTALLATION: Contractor. No <br /> Type of Pump,) .� H.P, <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR State, Work Done <br /> DESTRUCTION OF WELL: <br /> Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> 1 <br /> I hereby agree to comply with all laws and regulations of •the San Joaquin Local Health District s <br /> and the State of California pertaining to or regulating wel1"construction. Within FIFTEEN DAYS j <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 thewell in use. The above i <br /> information is true to the best of my,knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU,TjNG, D A FINAL' INSPECTIO } <br /> SIGNED TITLE <br /> (D W PLOT PLAN ON REVERSE S.ID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I vfi <br /> APPLICATION ACCEPTED*BY �' DATE <br /> ADDITIONAL COMMENTS,:. <br /> PHASE' II G OUT INSPECTI XPHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE .6' INSPECTION BY DATE <br /> i' <br /> E H 1426 Rev. • 1-74 <br />