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SAN -JOAQUIN LOCAL-HEALTH DISTRICT �-� <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. / <br /> . Telephone: (209) 456-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR. PUMP PERMIT Permit No. 0 <br /> GY <br /> THIS._PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued l7'� <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 acid the: Rules and Regulations of the, San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION "' fj ' R-9f CENSUS TRACT. <br /> Owner's Name Phone <br /> Address ` 4 1 City- 'Z j <br /> Contractor's Name �� �r License Phone4 <br /> F <br /> TYPE OF WORK (Check) ; NEW WELL /Zf--UEEPEN / / RECONDITION /_/ DESTRUCTION /r7 F <br /> PUMP INSTALLATION / / PUMP REPAIR / /- PUMP REPLACEMENT /_ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMES'T'IC WELL `J PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 4--C-able Tool Dia. of. Well. Excavation <br />^4==Domestic/private Drilled Dia, of Well Casing` <br /> Domestic/public Driven Gauge of CasingrA <br /> Irrigation Gravel Pack + _Depth of Grout Seal <br /> Cathodic Protection Rotary ; Type of Grout 9' ' - <br /> Disposal Other tOther Information <br /> GeophysicalSurface SeaZ� Installed.By : -' - <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ' <br /> PUMP REPLACEMENT: / / State Work Done . <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: -Well Diameter ApproximateyDepth <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 per tdifiing- to-6r'regul'atingwell'construction. `-Within"4iIFTEEN 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 well and notify them before putting. the. well in use.. The above <br /> information is true to the best of. my knowledge and belief. TWILL CALL FOR A GROUT .INSPECTION <br /> PRIOR TO GRO ING AND A FINAL INSP N, , <br /> SIGNED _ _ TITLE <br /> (DRAW PLOT PLAN ON REVERSE.SIDE) , <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 1-m-1 r7 <br /> ADDITIONAL. COMMENTS: <br /> PHASE II GROUViINSPECTION ,PRASE III/FINAL_ TNSPECT.ION� <br /> INSPECTION-BY' "- - ])ATS 1, n x INSPECTION ,BY DATE 04 T _Zp <br /> E H 1426 Rev. - I-74 n��77 2M <br />