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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE`-OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br />�r Telephones (209)t466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,6-,y34J, <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application in hereby made to the San Joaquin Local Health District fbr a permit to construct <br /> and/or install the work herein described. This application is shade 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 / CENSUS TRACT <br /> Owner s Name Phone G <br /> Address � Ca City " <br /> Contractor's Name Z&T License ,Z Phnne -�Z 1 <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN '/� RCONDITiONr/7�;.DESTRUC_ �_ <br /> TION J'? <br /> PUMP INSTALLATION / / PUMP REPAIRm/� PUMP REPLACEMLNT / <br /> Other <br /> DISTANCE = NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPO AL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL i <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation , <br /> _-Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public � _ Driven Gauge of Casing ' <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Groutl <br /> Disposal Other Other Information " <br /> Geophysical <br /> } . - Surface Seal Installed By - <br /> PUMP INSTALLATION: Contractor ( a <br /> Type .of Pump H.P. <br /> i <br /> PUMP REPLACEMENT: / State Work Done 9 <br /> PUMP '.REPAIR: <br /> / / State Work Done . <br /> DESTRUCTION OF WELL Well Diameter Approximate Depth <br /> Describe Material and .Prdcedure <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 j <br /> WELL DRILLERS REPORT of the well and notify them before-,putting the..well. in.use.... .The above i <br /> information is true to thembestmof my..kndwledge.and belief. I WILL CALL FOR A GROUT INSPECTION ' <br /> PRIOR TO GROUTING =A PIN NSPECTION. � <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE) ' <br /> PHASE I FOR DEPARTMENT USE ONLY j <br /> APPLICATION ACCEPTED By . _ __ __ _-- _ a. DATE _-I -Z s <br /> ADDITIONAL"COMMENTS.; <br /> PHASE II GROUT INSPECTION * PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE - 2=" , <br /> E H 1426 Rev. 144 <br />