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SAN JOAQUIN- LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE:' 1601 E. Hazelton Ave. , Stockton; Caiif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.-;-7,7 e�-t t; <br /> THIS PERMIT EXPIRES 1°= YEAR FROM DATE ISSUED Date Issued 7'Is -�� <br /> f <br /> (Complete In Triplicate) <br /> Applicatio 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, Joa'quin <br /> County Ordinance No. %1862 and the. Rules and Regulations of the San Joaquin Local Health: Distriet. <br /> JOB ADDRESS/LOCATION CENSUS TRACT ' . <br /> i <br /> Owner's NamePh ne <br /> 1 1epAddress City <br /> Contractor's Name License 1142�EZZ Phone <br /> J <br /> t TYPE OF WORK (Check) : NEW WELL / / DEEPEN%/ RECONDITION /_/ DESTRUCTION /7 _ <br /> PUMP INSTALLATION _/_/ PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES PIT PRIVY - -- - _�_.__-,• r <br /> SEWAGE DISPO A�IELD 11^0" CESSPOOL/SEEPAGE PIT _ OTHER <br /> PROPERTY LINE - PRIVATE ]JOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial `Cable Tool Dia. of Well Excavation � t <br /> k �( Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing -G <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> L <br /> Cathodic Protection Rotary Type of Grout a <br /> Disposal .' Other Other Information <br />' Geophysical Surface Seal Installed By: ��!�-�� <br /> i _. <br /> f PUMP INSTALLATION: Contractor <br /> f Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> E <br /> PUMP REPAIR: / / State Work Done <br /> I DESTRUCTION OF WELL: Well Diameter _� Approximate Depth Q <br /> 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 REPORT of the we3 and notify them before putting. the well in use.. . The above <br /> information is tr e to the be t o my knowledge and belief. I WILL C FOR A GROUTI/INSPECTION <br />, PRIOR TO GROUTIN AND A FIN CTIUN, r <br /> SIGNED fP TITLE <br />' f "(DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 14� DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE 11 GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY /° DATE // -/;f �F <br /> E H 1426 Rev. • 1-74 ���/7 _ 2M <br />