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JOAQUIN LOCAL HEALTH DISTRICT <br /> -,-FO OFFICE USE: 1601 E. Hazelton'Ave. , Stockton, Calif. <br /> 02 - Telephone: (209) 466-6781 <br /> AP ICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issueds7� <br /> 'e (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- andRegulations of ,the San Joaquin Local Health District. <br /> L <br /> JOB ADDRESS/LOCATION CENSUSTRACT <br /> Owner's Name Phone - � �- <br /> Address <br /> City <br /> Contractor's Name /ZO, License, # hone e <br /> TYPE OF WORK (Check): NEW WELL/ DEEPEN /7 RECONDITION -f7 DESTRUCTION �f <br /> } PUMP INSTALLATION � PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> f — <br /> DISTANCE TO NEAREST SEPTIC TANK EWER LINES PIT PRIVY <br /> SEWAGE DISP SALFIELD CESSPOOL/SEEPAGE PI—T zmeOTHER <br /> - <br /> PROPERI LINE J�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 , DriLlied iDia:,bf,Well Casing. <br /> Domestic/public Driven Gauge`of Casing777 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary 'Type of Grout ' . <br /> Disposal ► Other Other Information , <br /> Geophysical .Surface Seal Installed $ <br /> PUMP INSTALLATION: Contractor <br /> Type .of .Pump <br /> PUMP REPLACEMENT: , Lj -�,St at#WorDone <br /> PUMP '.REPAIR: w /� State Wiork,Done <br /> - <br /> DE&TRUCTION OF WELL: Well Diameter �' .�� ; 4 Approximate Depth i <br /> Describe; Material and Procedure . <br /> S <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 .S an'Jaaquin• Loca alth District a <br /> WELL DRILLERS REPORT of the-well and notify them before putting.theiaFell use.... .The above <br /> information is true to the-best; of- my.knowledge and. belief. I WILL CAL OR A,GROUT INSPECTION <br /> PRIOR TO GROUTING-AND A FI IA1 E CTION.}' <br /> SIGNED ;TIT <br /> t DRAW PLOTALAN ON REVERSE SIDE <br /> R DEPART USE ONLY 1 <br /> PHASE I <br /> APPLICATION ACCEPTED BG ;. DATE /G T2s <br /> ADDITIONAL COMMENTS: <br /> PHASa 2g2g INSPECTION PHASE I I FINAL INSPECTION , <br /> INSPECTION BY DATE INSPECTION BY DATE f 30 7"7 <br /> E H 1426 <br /> Rev. 1-74 ! t./7c oM a <br />