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�Y <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOfirOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <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 Ilealth.District fora 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 Regulation& of the //San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION -79. CY. CENSUS TRACT <br /> Owner's Name f A,a i< Phone , <br /> Address cS <br /> City <br /> Contractor's Name .S7,1 License Phone '&A! <br /> TYPE OF WORK (Check): NEW WELL '/7 DEEPEN J7 RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION/ / PUMP REPAIR -f PUMP REPLACEMENT <br /> -- ,Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 4 . <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL `v <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS \ ^ <br /> Industrial Cable Tool Dia. of Well Excavation V1 <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 Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump A.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP :REPAIR: State Work Done AD 0- <br /> Ln;421 <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth E 1E <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 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 GROUTING ANrhA JaNAL INSPECTION. <br /> SIGNED -A TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE . <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ' <br /> ADDITIONAL COMMENTS: m <br /> PHASE II GROUT INSPECTION P E I FINAL INSPECTION <br /> INSPECTION BY DATE. INSPECTION BY DATE <br /> vivr <br /> E H 1426 Rev. 1-74 h/75 2M <br />