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SAN JOA UIN LOCAL HEALTH DISTRICT <br /> FOF:.OFFICE USE 1601 E. Hazelton Ave. , ,Stockton, Calif. T <br /> Telephone: (209) 466-6781+ t <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP,PERMIT Permit No. <br /> l� <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is Aereby 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 a les and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> ' <br /> Owner'•s Name / / � �./ J /� P l/_ 9 I <br /> 6Q hone <br /> Address G+ /�1 r1/� <br /> City 19U� <br /> Contractor's Name f d <br /> License # Phone <br /> 1 <br /> TYPE OF WORK (Check) NEW WELL / DEEP /`/ RECONDITI~ L /� DESTRUCTION /� <br /> PUMP INSTALLATION / / PUMP. REPAIR /�/ PUMP REPLACEMENT /_7 <br /> .� Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER 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 /> 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 E <br /> Geophysical <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump t H.'P. <br /> PUMP REPLACEMENT: State Work Done. E <br /> ,.�_. D <br /> PUMP :REPAIR: //� 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 :strict <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 /> WELT, DRILLERS REPORT of the well and notifybefore <br /> them putting the-well in uses. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTIQiJ; <br />?RIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> PL PLAN ON REVERSE SIDE) . <br /> DEPARTMENT USE ONLY <br /> PHASE I XA <br /> APPLICATION ACCEPTED BYTE <br /> ADDITIONAL COMMENTS: <br /> PHASE I GR T IN ECT N P / AL INSPECTION <br /> INSPECTION $Y E INSPECTION BY .r,�DATE r--Z, z. <br /> E H '1426 Rev. 1-74 1 f.N 2M <br />