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,.. SAN JOAQUIN LOCAL HEALTH DISTRICT - ')-� <br /> FOR(OFFICE USE: 1601 E. Hazelton Ave. , Stockton, , Calif <br /> r r <br /> Telephone: (209) 466-6781 i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR. FROM tDATE ISSUED Date I66ue <br /> d <br /> (Complete In Triplicate) <br /> Application is hereby made to the Sari: Joaquin Local Health District,for a' permit to'construct' I <br /> and/or install the work herein described. This application is made .iia -compliance with San Joaquin ; <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquitf Local Health District° ' <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone <br /> Address �7 �L. /�i� - - City - <br /> Contractor's Name <br /> �r. License l Phone <br /> I <br /> TYPE OF WORK (Check): NEWl,WELL /% DEEPEN /7 RECONDITION /7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR /% PUMP REPLACEMENT.. /7 <br /> Other <br /> DISTANCE,TO NEAREST: SEPTIC TANK SEWER-LINES;" PIT PRIVY <br /> SEWAGE DISPOSAL FIELD " '0tifCESSPOOL/SEEPAGE PIT*­ OTHER <br /> PROPERTY LINE -'PRIVATE B6RESTIC'WELT.'__ PUBLIC ~DOMES"TIC WELL <br /> INTENDED USE TYPE OF WELLx' k CONSTRUCTION SPECIFICATIONS <br /> Industrial f Cable' Tool - Dia. of Well Excavation <br /> .Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public DrivenGauge of Casing, <br /> Irrigation - " " n . Gravel Pack R Depth of Grout Seal <br /> Cathodic Disposal protection ��-Rotary--. e�Y� `;. —Othof Grout# <br /> lnformation • . � j <br /> Geophysical Surf ace.Seal Installed BY: tJ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> I <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: State Work Done <br /> ,D_ESTRUCTION OF WELL: Well Diameter Approximate Depth �5 U <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of .the San Soaquin' 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 INSPECTIO a <br /> PRIOR. 'TO GROU IN A F NAL INSPECTION: <br /> SIGNED TITLE G9-GCi—ne�� <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY / DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II 2P T INSPECTION PHASETIj//FINA1, INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE IQ-/-7� <br /> + E H 1426 Rev. 1-774 1-74 2M <br />