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ti <br /> SAN JOAQUIN LOCAL HEALTH+DISTRICT <br /> FOR,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> I Telephone: (209) 456-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.� <br /> TRIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3/ <br /> jI (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 /> t' JOB ADDRESS/LOCATIONCENSUS TRACT <br /> y f <br /> bwner's NameP&A :01-ACARA <br /> Phone ' <br /> i Address tf 2 A/ A City _L• ! , <br /> Contractor's NAme License <br /> one <br /> TYPE OF WORK (Check): NEW WELL!/(DEEPEN / / RECONDITION /? DESTRUCTION %f <br /> PUMP:�INSTALLATION / / PUMP REPAIR /% PUMP REPLACEMENT /7 <br /> r Other /_7 <br /> — <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER 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 _ <br /> Industrial L,.--Cable Tool. Dia. of Well Excavation F4\ i <br /> Domestic/private Drilled `Dia. of Well Casing �• q <br /> Domestic/public f Driven Gauge of Casing y1ofN <br /> f/Trrigation Gravel Pack Depth of Grout Seal, A <br /> CathodicaProtection Rotary. Type of Grout <br /> a <br /> Disposal Other ��„'� t..�As, 6tlier Znformati.on--.�_ <br /> Geophysical) Surface Seal Installed B <br /> PUMP INSTALLATION: <br /> Contzcactor r.. <br /> Type .of Pump H.P. <br /> PUMP RE +� <br /> PLACEMENT: / /' State Work Done• <br /> PUMP ,REPAIR: <br /> /-7 State Work Done <br /> ESIRUCTION 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 District �p <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 LocalHealth District a <br /> WELL DRILLERS REPORT of the 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 FOR A GROUT INSPECTION <br /> PRIOR TO'GROU G D A FINAL jNSoPECT ION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> PHASE = FOR DEPARTMENT USE ONLY <br /> w <br /> APPLICATION ACCEPTED :BY DATE <br /> ADDITIONAL COMMENTS:' i <br /> ” . <br /> INSPECTION BY PHASE II GROUT INSPECTION PHASE IIWINAL INSPECTION <br /> DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1 4 <br />`� 1-74 2M _ , <br />