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W T _ <br /> C4l� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFi,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 7d-93*r <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 Distrir-.,- <br /> JOB ADDRESS/LOCATION,,9,� / CENSUS TRACT <br /> ov <br /> Owner's Name Phone �a <br /> Address ���s�. City <br /> Contractor's Name �' License #/G 1,3 Z3 Phone <br /> TYPE OF WORK (Check): NEW WELL � DEEPEN '/7 RECONDITION DESTRUCTION /7 <br /> PUMP INSTALLATION &' PUMP REPAIR '/-7—PUMP REPLACEMENT /7 <br /> Other /% <br /> DISTANCE TO NEAREST: SEPTIC TANK ,Vd SEWER LINES ,�a r_ PIT PRIVY <br /> SEWAGE DISPOSAL FIELD /00" CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE — PRIVATE DOMESTIC WELL Ste_' 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 Driven Gauge of Casing / <br /> Irrigation Gravel Pack Depth o£ Grout Seal <br /> Cathodic ProtectionRotary Type of Grout , <br /> Disposal Other Other In€ormation <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. / <br /> PUMP REPLACEMENT /7 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 kno edge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO N AND A IN INSPECTIO . <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYZ �6 DATE �dXXX-7/, <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE /U.- _ INSPECTION BY ✓ DATE <br /> E H 1426 Rev. 1-74 <br />