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SAN JOAQUIN LOCAL HEALTH DISTRICT N <br /> FOh _OFFICE USE: / 1601 E. Hazelton Ave. , Stockton, Calif. 0 <br /> Telephone:p (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the•,San Joaquin Local Health District for- a 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 /> JD$ ADDRESS/LOCATIONAlke <br /> CENSUS TRACT ' <br /> Owner's Name _V 0 <br /> Phone <br /> Address -1.1 16 } <br /> cY. City �, d <br /> Contractor's Name ,- License Phone <br /> _ e <br /> TYPE OF WORK (Check) ; NEW WELL / If'�DEEPEN / RECONDITION / / DESTRUCTION /77 <br /> PUMP INSTALLATION PUMP REPAIR / PUMP REPLACEMENT' <br /> 0 ther / / -- <br /> DISTANCE TO NEAREST; SEPTIC TANK 7 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD':---/j0 CESSPOOL/SEEPAGE PIT,;57/_S_0 U OTHER { <br /> PROPERTY LIPRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL ; <br /> INTENDED USE TYPE OF OF WELL CONSTRUCTION SPECIFICATIONS -� <br /> Industrial :• Cable Tool Dia. of Well Excavation I! <br /> Domestic/private Drilled Dia. of Well Casing ^ <br /> Domestic/public Driven Gauge of Casing z: <br /> Irrigation Gravel Pack Depth of Grout Seal _ <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical 'Surface Seal Install.ed'-B <br />'UMP INSTALLATION: Contractor <br /> Type of Pump - ' <br />'UMP REPLACEMENT: / / State Work Done <br />'UMP .REPAIR: / / State Work Done <br /> ESTRUCTION OF WELL; Well Diameter r <br /> Approximate Depth <br /> Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local #Health District <br />.nd the State of California pertaining to or regulating wrell 'construction. Within FIFTEEN DAYS— >y <br /> fter completion of my work on a new well, I will furnish the San Joaquin Local �Health District a <br />`ELL DRILLERS REPORT of the well and notify them before putting. the. well in use.. The above <br /> nformation is true to the best of my knowledge and belief: I WILL CALL FOR A GROUT INSPECTION <br /> RIOR TO GROUTING AND A FINAL INSPECTION <br /> IGNED ell <br /> TITLE, <br /> (DRAW PLOT PLAN ON REVERSE SIDE) ' <br /> RASE I <br /> FO DEPARTMENT USE ONLY <br /> PPLICATION ACCEPTED BY - - <br /> DDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION eiE /FTN INSPECTI N i <br /> 9SPECTION BY DATE INSPECT' ATP <br /> E H 1426 Rev. - I-74 77 ��. <br />