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�'�`� SAN JOAQUIN LOCAL HEALTH DISTRICT - J <br /> FOR OFFICE USE: yyy 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 4. Telephone_: (201), 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> �-4kir1J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issue _ <br /> t/I©4 0 F_ G o�sTbG� d-4C�(Complete In Triplicate) ,J : n��-Z22� <br /> Appliceition is hereby made to the San Joaquin Local. Health District ora 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 IMDREWIACATION i`!�" CENSUS TRACT <br /> Owner's Name _ p Phone j <br /> Address City <br /> Contractor's Name ave a va License <br /> TYPE OF WORK (Check) : NEW WELL& DEEPEN/? RECONDITION /7 DESTRUCTION f7 <br /> PUMP INS ALLATION � PUMP REPAIR /� PUMP REPLACEMENT- /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD - CESSPOOL/SEEPAGE PIT OTHER `-`- <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL/..fVPUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ' q Cable Tool-., Dia. of Well Excavation l� <br /> _ Domestic/private '�`-­�V Drilled Dia. of Well Casing <br /> Domestic/public rDjiven_____ Gauge of, Casing - ey0 <br /> Irrigation Gravel''Pack� -Depth of',`Grout Seal <br /> Cathodic Protection Rotary Type of_Grout <br /> Disposal �r': Other Other Information <br /> .Geophysical � 7Surface Seal Installed <br /> o Y � <br /> PUMP INSTALLATION: Contractor <br /> ype.gf {Pump _ ,� H.P., . <br /> PUMP REPLACEMENT: / / State Work Done <br /> I, <br /> PUMP :REPAIR: <br /> • 0 State Work Done # <br /> ES,TRUCTION OF WELL: Well Diameter Approximate Depth <br /> i Describe Material and Procedure <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. 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 REPORTioflthe 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 FORA GROUT INSPECTION <br /> PRIOR TO GROUTANG AND A4FINAL INSPECTION. ! <br /> SIGNED + a TITLE - + <br /> -DRAW PLOT PL-AN-ON REVERSE-SIDE - <br /> .,......FOR._.D$PARTMENT\USE_ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _ DATE <br /> ADDITIONAL COMMENTS: <br /> . PHASE ROUT SPECTION PHASE II IN PECTION <br /> INSPECTION BY ATE o-2 INSPECTION BY <br /> E H 1426 Rev. 1-7 ®® 1-74 2M_„P <br />