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t / SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE 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 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 /> 1{') kv <br /> JOB ADDRESS/LO A TON �' CENSUS TRACT <br /> Owner's Name Phone &3 3 0 <br /> Address / City <br /> Contractor's Name % \, License #/4 Z373 Phone3c. <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/ / RECONDITION / / DESTRUCTION . <br /> PUMP INSTALLATION_/ / PUMP REPAIR �—P REPLACEMENT <br /> Other / / $ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT IRIVY <br /> SEWAGE DISPOSAL FIELD _ CESSPOOL/SEEPAGE PIAT OTHE-R, �� <br /> PROPERTY LINE _ PRIVATE DOMESTIC WELL UBN DOMESTid �ELL <br /> INTENDED USE TYPE OF WELL CONST UCTZO, ',SPECIFIMIO S . <br /> , Industrial. Cable Tool Dia. of Well Excavafio� <br /> ----,";Domestic/private Drilled Dia. of Well (using <br /> `Domestic/public ��'?,+. ...,DrivenGauge of Casing <br /> Irri ation }Gra rel Pick Depth of Grou eal' \`Lr <br /> -- <br /> Cathodic Protection Rotary Type of Grout . <br /> Disposal Other Other Inf ormat ion <br /> Geophysical. Surface Seal stalled By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / J State Work Done <br /> PUMP .REPAIR: >4' State Work Donef <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the SaJoaquin Local Health District <br /> t <br /> and the State of California pertaining to or regulating well '-con truction. Within FIFTEEN DAYS- <br /> after completion of my work on a new well, I will furnish the S4 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 rue to the best of my- knowledge and belief. I W LL L FOR A GROUT bNSPECTION <br /> PRIOR TO GROUff.M2kD A E&f INSPECTIA. 1 <br /> SIGNED TITLI <br /> DRAW-PLOT PLAN ON RE•. ERSE S DE) <br /> FOR DEPARTMENT_\ijS.E;.ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE -9/2 ? .. <br /> ADDITIONAL COMMENTS: loci <br /> PHASE II GROUT INSPECTIM PHASE III/FINAL INSPECT ON l / <br /> INSPECTION BY DATE INSPECTION BY DATE )0 <br /> E H 1426 T Rev. 1-74 376 2M <br />