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f: s <br /> I <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOErOFFICE USE: 1//1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Ts` oD� <br /> THIS PERMIT EXPIRES 1 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 /> pp ,, � F/ N � <br /> JOB ADDRESS/LOCATION �e �-d-t ,O,P (J c NSUS ''TRACT <br /> Owner's Name r Phone <br /> Address Cit f I <br /> Y <br /> Contractor's Name - - License M X3 73 Phone�� 1 <br /> k <br /> TYPE OF WORK (Check) : NEW WELL/7 DEEPEN /7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR j�_y? PUMP REPLACEMENT 1_7 <br /> I <br /> Other /j <br /> a <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 <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 Grout <br /> Disposal ,,Other_; k Other Information <br /> Geophysical , Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. `_ <br /> PUMP REPLACEMENT: %/..Y S tate Work ,Done <br /> PUMP:REPAIR: ` state Work Done <br /> 01RUCTION OF WELL: Well Diameter 4 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 N <br /> and the State of California pertaining to or regu at'Ing well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I willifurnish the San Joaquin Local Health District 4 ' <br /> WELL DRILLERS REPORT of the well and notify them before putting. the..well in.use.. The above VVVV y <br /> I <br /> information is true to the best of- my knowledge and belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO GROUT AN A FI NSPECTION. d <br /> SIGNED TITLE _ <br /> 9ALORAW PLOT PLAN ON REVERSE SIDE) <br /> --- <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I f <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II UT I SPE Ifl PHASE III/FINAL INSPECTION I�VI <br /> INSPECTION BY DATE INSPECTION BY /t DATE <br /> t <br /> E H 1426 Rev. _1-74 <br /> 1-74 7M I <br />