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�,/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOP- <br /> OFFICE USE: /� 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> " <br />' THIS PERMIT'EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued <br /> 4 (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 ancl' the R les and Re ulationsof as San uin Local Health District. <br /> .TOB ADDRESS/LOCATION Z ��� F, ,ANG/ <br /> ENSUS TRACT <br />' Owner's Name <br /> Phone -- <br /> Address <br /> City r <br /> Contractor's Name License 4E Phone _ <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN _ <br /> RECONDITION /% DESTRUCTION /_7 <br /> PUMP INSTALLATION /Z� PUMP REPAIR/ / PUMP REPLACEMENT 17 <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 /> Iridustrial 4" Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br />=ZDomestic/public Driven ; Gauge of Casing <br /> ;—: Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic 'Protection Rotary Type of Grout <br /> Disposal Other yp <br /> Other Information <br /> Geophysical Surface Seal installed BY: <br />'UMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. • is <br />'UMP REPLACEMENT: State Work Doric <br /> ''­`1 / / State Work Done <br /> t <br /> ES<TRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> y �N :. <br /> hereby agree to comply withall laws and regulations of the San Joaquin Local' Health District <br /> nd the State of California pertaining- o or.-r-egulating well "construct"i"on. "z. Within FIFTEEN DAYS <br /> fter completion of my work on a new well, 1 will furnish the San Joaquin Local Health District <br /> ELL DRILLERS REPORT of the well and notify them before putting the welkin" use. The above <br /> nformation is true to-the best" of. my.:knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> 3IOR TO GROUTING.-ANb A .FINAL INSPECTION. <br /> IGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> RASE-' I p <br /> PPLICATION ACCEPTED BY rr <br /> DDITIONAL COMMENTS: #"DATE <br /> PHASE II GROUT INSPECTION PHA E - /FIN -`INSPECTION " <br /> gSPECTION BY DATE INSPECTION BY <br />—E-H 1426 Rev. 1-74 <br /> 1X77. : 2PI 1 <br />