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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF0IFC E: 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 LT_=Z7 <br /> (Complete In Triplicate) <br /> application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> ind/or install the work herein described. This application is made in compliance with San Joaquin <br />:ounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br />[OB ADDRESS/LOCATION ---At"e i N S 4 1-4 It AO , CENSUS TRACT <br />)wner's Name / Phone <br /> address /G t-c,) a iC 6 City . . <br />;ontractor's Name / License # 493_?,. Phone <br />'YPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR /jC/_PUMP REPLACEMENT /-7 <br /> Other <br /> 1STANCE 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 \T . <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 of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br />'UMP INSTALLATION: Contractor r ' <br /> v <br /> Type of Pump d✓ H.P. <br />'UMP REPLACEMENT: / / State Work Done <br />'UMP .REPAIR: /k/ State Work Done � V , <br /> ES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> nd the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> fter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> SELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> nformation is true to the best of my knoWled e and elief. I WILL CALL FOR A GROUT INSPECTION <br /> RIOR TO GROUTI G AND A FINAL INSPECTION, <br /> IGNED TITLE <br /> (DT AN ON KETERSE SIDE) <br /> OR DEPARTMENT USE ONLY <br />'HASE I <br />.PPLICATION ACCEPTED BY NMDATE_ <br />,DDITIONAL COMMENTS: <br /> PHASE II GR SPECTION PHASE III/FINAL INSPECTIO <br /> NSPECTION BY DATE INSPECTION BY 6V DATE <br /> E H 1426 Rev. - 1-74 <br /> 6/77 2M <br />