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} <br /> t a a• /�- +� SAN JO <br /> AQUIN LOCAL HEALTH DISTRICT ---- <br /> FOR!'OFF�USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> , .. Telephone: (209) 466-67811 , <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <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 pert to construct <br /> and/or install the work herein described. This application is t,ade 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/LOCATION /0.2 S'?/ 40A J'A0 CENSUS TRACT <br /> Owner's Name � - Phone <br /> Address Cityr�,�.a/o�-� <br /> Contractor's Name ' ) , License # hone <br /> 0j <br /> L TYPE OF WORK (Check): NEW WELL '/? DEEPEN -/—/- RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR 07PUMP REPLACEMENT /7 <br /> Other U. - <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 <br /> TYPE OF WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool 4 Dia. of Well Excavation <br /> )C Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation _�.._.._ Graved Pack Depth of Grout Seal - - - - <br /> Cathodic <br /> eal - - - -Cathodic Protection t ctian Rotar <br /> y Type of Grout <br /> Disposal Other � - Other Information <br /> - Geophysical Surface Seal. Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ,- ,� H.P. / <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP '.REPAIR: State Work Done ,e-40 <br /> ES;TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby-agree to comply with all laws and regulations of the San Joaquin Local Health' Aistrict <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 j <br /> information is true to the-best -of my .knowle <br /> D A FINALPE0 nd belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO UTING AN <br /> I SIGNED TLE r <br />` LQ Y PLAN QN RSE SIDE <br /> 0 .DEPARTMENT USE ONLY I <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE y� <br /> it ADDITIONAL COMMENTS: <br /> PHASE II GRO P TI PHASE0UFINALjjINSPECTIQN Ij <br /> INSPECTION BY DATE INSPECTION BY TE <br /> 1 E H 1426 Rev. 1-74 <br /> 1-7b 2M ' <br />