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_ `j SAN JOAQUIN LOCAL HEALTH DISTRICT V <br /> OR OFFICE USE: ° ` 1601, E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 / <br /> -� APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 5 <br /> 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. 1.862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Al: ,� C AW Lac±�,r:��' � Phone <br /> Address City ei ` <br /> Contractor's �Name`' ,; v License, _ <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / 7 PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK-x� SEWER LINES ,,a ' PIT PRIVY <br /> SEWAGE DISP Sv AL FIELD ;_ .R` CESSPOOL/SEEPAGE PIT OTHER , <br /> PROPERTY LINE/a"PRIVATE DOMESTIC WELD PUBLIC DOMESTIC WELL - - � <br /> INTENDED USE TYPE OF WELL _ CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> --,k:: Domestic/private ,)C Drilled Dia, of Well Casing (, <br /> Domestic/public Driven _ Gauge of Casing < <br /> Irrigation f Gravel Pack Depth of Grout Seal <br /> Cathodic Protection >,r, Rotary Type of Grout r' .L._ �,�T <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By:,� /",4//, , e, :r , <br /> PUMP INSTALLATION: Contractor y <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <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 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 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 GROUTING AND A FINA INSPECTION. <br /> SIGNED TITLE -�f �- <br /> (D W !JOT PLAN ON REVERSE SIDE) <br /> -' OR DEPARTMENT USE ONLY <br /> PHASE I ` <br /> APPLICATION ACCEPTED BY ; , DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE IIOMT T I SPE N PHASE III/FINAL INSPECTION <br /> INSPECTION BY / ATE INSPECTION BY DATE <br /> ff <br /> E H 1426 Rev. - 1-74 <br />