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LSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFF E USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> �. APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ]],�aa'/jo <br /> r 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 andithe Rules and Regulations of the Sa Joaquin Local Health District. <br /> /7 740 F /, dl 'A R, � eA <br /> JOB ADDRESS/LOCATION . S" r! ®r' CENSUS TRACT <br /> Owner's Name 3`�usez_ Phone <br /> Address 0 �z C zC4a, City <br /> Contractor's Name rJ ®, bon License # / -7b`Phone <br /> t <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/' / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT <br /> ,.. Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LIFE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL � f <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation v <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> ._ c Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout T}I. <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /_/ State Work Done <br /> PUMP REPAIR: ',�W/- :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 putting- the.wel1 in use.. The above <br /> information is true to the best of.-my kno-wwletdge acid bel ef. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTI G AND A FINAL INSPECTI <br /> SIGNED TLE <br /> ''(D P PLTff ION REVS .E SIDE) <br /> F DEPARTMENT USE ONLY 4 <br /> PHASE I <br /> APPLICATION ACCEPTED BY � �,.yl��, _ _ DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE .II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 2M <br /> E H-1426 Rev. - I-74 <br /> 6�7.� <br />