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LI- <br /> SAN' JOAQUIN LOCAL HEALTH DISTRICT <br /> I0&.OFFICE USE: i% 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <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 /> i County Ordinance No. 1862 and the: Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION iii>i s�n� rF ,�c ;',•�;4- l'rt � .:,�/c. s' t, N <br /> r 1 c , ,. � ,,z , - CENSUS TRACT <br /> Owner's Name Phone <br /> Address ``J' /_3`' .•'�% i' <br /> City , c./,/ <br /> Contractor's Namee <br /> License # ^_ Phone <br /> TYPE OF WORK (Check) : N y �aEEPEN / 7 RECONDITT NN/7 DESTRUCTION /_7 <br /> PUMP Itis"=ALSn 'ION /_/ PUMP REPAIR <br /> 0Otherrt' <br /> R/'­PUMP REPLACEMENT 17 <br /> i <br /> DISTANCE TO NEAREST: SEPTfC TANK_ ..•w_- SEWER LINES PIT PRIVY <br /> SEWAGE )I5 'i: FIELD __ CESSPOOL/SEEPAGE PIT OTHER <br /> PROPER['` 1 .1N7 - PRIVATE DOMESTIC WELL PUBLIC DOMESTI <br /> IOrC WELL <br /> NTENDED USE TYPE `WELL CONSTRUCTION SPECIFICATIONS `J <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private ;gilled Dia. of Well Casing ^ <br /> Domestic/public _ - Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection ' Rotary Type of Grout <br /> Disposal Other Other Information V <br /> Geophysical `T --�---�— <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 2, <br /> H.P. <br /> PUMP REPLACEMENT: �`. <br /> State Mork Done � <br /> PUMP .REPAIR: / +J State Work Done � ,A A// <br /> DES°TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply with al _aws 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 neer 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 FINAL INSPECTION. <br /> SIGNED •-� _ - ':��_� � �k � � � g: `�,u <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> A PLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE IZ1 ,j ii <br /> PHASE II G1ffUT INSPECTION PHASE III FINAL�N -i <br /> INSPECTION BY DATE <br /> INSPECTION BY z � !/ <br /> E H 1426 Rev. 1-74 h/7q 7M <br />