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n. ►/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF:;0 ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> F Telephone: (209) 466-6781 <br /> F ' APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Na. <br /> THIS PERMIT EXPIRES 1 YEAR FROM.DATE ISSUED Date Issued <br /> ,o-7-.2r <br /> I A y (Complete In Triplicate) <br /> PPlication is iiereb 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 Sen Joaquin <br /> , County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION / l} � CENSUS TRACT <br /> Owner's Name Phone <br /> 'Address'. a21 6 <br /> City ' <br /> Contractor's Name' E License f` Plsone a. <br /> TYPE OF WORK (Check) : NEW WELL -/7 DEEPEN /_7 RECONDITION <br /> /7 DESTRUCTION /_7PUMP INSTALLATION LTI PUMP REPAIR /?_ <br /> PUMP REPLACEMENT F7 <br /> Other / / — <br /> j 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 Cable Tool Dia. of Well Excavation <br /> � ZE ' 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 Other Information <br /> Geophysical - -... Surface Seal' Installed B <br /> i <br /> PUMP INSTALLATION., Contractor <br /> Type of Pump H.P. <br /> PUMP State Work DoneZl"Ir <br /> PUMP '.REPAIR: State Work Done <br /> llE&TRUCTION OF WELL: , Well Diameter <br /> 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 <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 Sara Joaquin Local Health District a <br /> WELL- DRILLERS REPORT of the well and notify them before puttingthe .well. in.use.. . .The above # <br /> `information is true 'tothe• of. ow ge and belief. I WILL CALL FOR A -GROUT INSPECTION <br /> PRIOR TO GR UTING AND A FIN I N. <br /> SIGNED <br /> TITLE <br /> (D W PLOT PL REVERSE SID-EFa <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYZ� <br /> DATE may" f� <br /> ADDITIONAL COMMENTS: <br /> PHASE II G E ON PHASE III INAL INSPECTION <br /> INSPECTION BY ATE INSPECTION BY DATE <br /> - E H 1426 Rev. 1-74 <br />