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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> 4 <br /> FOE OFFICE USE: K1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> I ' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made t� 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 /> JOB ADDRESS/LOCATION /y? �' CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address City ICAr <br /> „ .. <br /> I Contractor's Name License # Phone <br /> y� i <br /> t TYPE OF WORK (Check) : NEW WELL/% 114i-PEN %% RECONDITION /_% DESTRUCTION <br /> f ;PUMP INSTALLATION / / PUMP REPAIR � PUMP REPLACEMENT /_7 <br /> Other,. <br /> J k <br /> 4 DISTANCE TONEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE1DISPOSAL FIELD CSSPOOL/SEEPAGE PIT _ OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL t CONSTRUCTION SPECIFICATIONS � . <br /> Industrial .1 Cable Tool D -a _ of Well Excavation <br /> I Domestic/private t Drilled Df A. of Well Casing <br /> j Domestic/public Driven Gpge of Casing <br /> Irrigation 1 Gravel Pack Depth -of Grout Seal <br /> Cathodic Protection I Rotary ,Tyne of Grout <br /> Disposal I Other Other Informa o ' <br /> Geo h 'sical `-, <br /> ti n <br /> p y S f <br /> ace Seal Installed B <br /> PUMP ,INSTALLATION: Contractor <br /> a _. ''„.a `, 5ype9f1Puml? H P <br /> s <br /> PUMP REPLACEMENT: J / 'State Wo-rkZ Dona <br /> i <br /> - 'T'a�•3' x h <br /> PUMP .REPAIR,� y' �State Work Done cfi <br /> I'. I !.-_._.1 . <br /> DES•TRUCTIONIOF WELL: Well Diameter _ Approximate Depth <br /> Describe Material and Procedure <br /> I hereby ag 1,7 <br /> ee to comply withl,all laws and regulations of the San Joaquin Local Health District <br /> and the State-of California'pe.rtaining to or regulatLng 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 DRILLER;-S, REPORT of the well and notify them be Are 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 GR� G hND Al.,INSPE ION. <br /> SIGNED TITLE <br /> j t DRAW PUT PLAN SON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY too <br /> PHASE I I <br /> APPLICATION ACCEPTED BY DATE _2 �C <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT I14SPECTION PHA_ + I/ INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE V_P.a <br /> f <br /> E H 1426 Rev. -l-74 , 3/76 2M ' <br />