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�U SAN JOAQUIN LOCAL HEALTH DISTRICT Y <br /> FOfi.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 ! 7� <br /> (Complete In Triplicate). , <br /> Application .is,hereby made to the San Joaquin Local health District for a permit to construct ' <br />• <br /> and/or instal9l 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/LOCATIONS .CENSUS TRACT <br /> Owner's Name f, 'i Phone , 7- 3'-1'7 z <br /> ~ <br /> Address � y . <br /> - Cit ' ` <br /> Contractor's Name Gf/ License # � 6� Phone <br /> TYPE OF WORK (Check): NEW WELL /. DEEPEN /7 RECONDITION /-7. DESTRUCTION /_7' <br /> PUMP INS AL TION 17 PUMP REPAIR'i7 PumP REPLACEMENT /7 <br /> } <br /> Other L_1 <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 „TYPE OF WELL CONSTRUCTION SPECIFICATIONS �l <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 4 2k <br /> �] <br /> Irrigation Gravel Pack Depth of-Grout Seal r 1 <br /> Cathodic iProtection l Rotary k Type of 'Grout l <br /> Disposal :, . Other ; '3 -- Other Inioramtion <br /> Geophysical - ' Surface Seal-Installed 'By: <br />[ .PUMP INSTALLATION:--- Contractor <br /> -Type l,of Pum H.P. <br /> i <br /> PUMP REPLACEMENT: / / State Work Done S <br /> PUME' 'REPAIR: /7 :State Work Done <br /> DESTRUCTION OF WELL: Well Diameter i Approximate Depth <br /> Describe Material and Procedure <br /> I kereby agree to comply with all laws and regulations of the San .Joaquin'Local Health District <br /> and the .S tate of California'.fpertaining to or regulating. _w.e11 `cons.truction.. ,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 <br /> informatiois is true to-the,blest of my:knowledge,,and belief:',' I WILL`GALT, FOR 'A GROUT INSPECTION <br /> PRIOR TO G OUTNG D A NAI, INSPECTION. <br /> SIGNED —TITLE-- <br /> . (DRAW <br /> TITLE—DRAW PLOT PLAN.ON REVERSE SIDE <br /> FOR,MEPARTMENT'USE ONLY <br /> f PHASE I <br />' APPLICATION ACCEPTED BY ,. DATE <br /> ADDITIONAL COMMENTS nl <br /> PHASF, II GROIJT INSPECTION PHASE II FIN PECT 0 <br />' INSPECTION BY i - DATE INSPECTION BY DATE . <br /> E.H 1426 Rev. 1-74 _h/75 2M_ <br />