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'v SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO41OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> APPLICATION TFOR p6 <br /> WELLhorie.CONSTRUCTIONOR1PUMP PERMITt .SAO t,J <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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS az CENSUS TRACT <br /> Owner's Name Phone <br /> Address City <br /> i Contractor's Name 17! License �,�f/� Phone , � <br /> TYPE OF WORK (Check): NEW WELL DEEPEN/7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION —PUMP/ PUMP REPAIR /_7 REPLACEMENT /7 <br /> Other /7 <br /> DISTANCE TO NEAREST: SEPTIC TANKZeQa 5EWER LINES/,' e7 PIT PRIVY r--� <br /> SEWAGE DISPOSAL FIELD — CESSPOOL/SEEPAGE PIT L--OTHER <br /> PROPERTY-LINE "- PRIVATE DOMESTIC WELlAW_+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 <br /> i Domestic/public Driven Gauge ofCasing <br /> a pc� <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout t <br /> s Disposal r0ther Other In€ormatibn <br /> Geophysical Surface_Seal'Installed BY: <br /> PUMP INSTALLATION: Contractor , p Z,00 <br /> Type of Pump t H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP '.REPAIR: /7 State Work Done _ <br /> f t <br /> d2ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> - _ Describe Material-and-Procedure <br /> E <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 /> Ifter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> 4ELL 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 FINAL INSPE CTI <br /> SIGNED - TITLE <br /> ( PLOT P ,ON REVERSE SIDE ' <br /> FOR nPIPARTMF.WT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED B DATE r <br /> ADDITIONAL COMMENTS: <br /> PHAS II ROUT INSPECTION PRAY I FI SPECTION <br /> INSPECTION DATE -/%- ? INSPECTION B TE <br /> t E S 1426 Rev. 1-74 1-74 2M <br />