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-4 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave, , Stockton, Calif. 3 <br /> Telephone: (209) 466-6781 (/ <br /> AV APPLICATION FOR WELL CONSTRUCTION`OR P SAP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3r9A Z <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 /> �?.f.g-0 tA), F c. v sT° : Z.Sd- i sa-Q3 <br /> JOB ADDRESS/LOCATION CENs S TRAC <br /> V {i <br /> Owner's Name Phone <br /> Address ,( City <br /> Contractor's Name License # Q220&4 Phone J <br /> ,t <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN RECONDITION RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC. TANK ��� SEWER LINES ''.PIT PRIVY <br /> t, <br /> SEWAGE._DISPOSAL FIELD , S2+ CESSPOOL/SEEPAGE PIT OTHER Gt�EZC--/�� <br /> PRQ-'ERTY' INE = PRIVATE DOMESTIC WELL 'PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable`�,Tbo'l•. Dia, of Well Excavation <br /> Domestic/private Dr-idled ��' r� Dia-'.s of Well Casing, <br /> Domestic/public Driven - _ _'` Gauge of Casing X �. <br /> Irrigation Gravel Pack Depth of Grout_ Seal <br /> Irrigation <br /> Qr <br /> Ca-thodic Protection Rotary Type of Grout '`o <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done �' n <br /> PUMP REBAIR: / / State Work Done ` <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 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 puttingthewell 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 UTING AN INAL INSP CTI N <br /> SIGNED TITLE �� _ <br /> (DRAW PLOT FL N REVERSE SIDE} 1 <br /> PHASE I <br /> FOR DEPAETMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATF � <br /> ADDITIONAL COMMENTS: <br /> PRASE II GROUT INSPECTION PHASE III/FINAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. � 1- 74 2M� <br />