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,�i� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFyF.IUSE. 6Q1 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 /> - <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 Joaquih , <br /> County Ordinance No. .•C 2 the RRules .,�Lnd Regulations of the San Joaquin Local Health District. <br /> pC o <br /> JOB ADDRESS/LOCATION _A, 1aA CENSUS TRACT <br /> Owner's.Name ���j f�'iY3(� i Phone_ ,7`7`. <br /> i <br /> Address (1Q [,f.sA,P�i1� l�.tx� _.� City �I <br /> Contractor's Name ° e-/ .License # <br /> ZdaPhone <br /> TYPE, OF#WORK (Check) : NEW WELL DEEPEN RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT / <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK L SEWER LINES f ! 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 SPECIFICATIONSx <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/privateDrilled Dia. of Well Casing <br /> Domestic_ <br /> /public - r.Driven �- Gauge .of•of- Casing <br /> - ° <br /> _. S flcfe <br /> Ixrigaon - Gravel Pack . Depth of Grout Seal <br /> Cathodic Protection —X- Rotary Type of Grout _ l�l- /2[:f� (Aj <br /> Disposal Other Other Information ° <br /> Geophysical Surface Seal Installed By: { <br /> PUMP INSTALLATION: Contractor I <br /> Type of Pump H.P. <br /> PUMP 'REPLACEMENT: / / State Work Done r <br /> PUMP .REPAIR: / / State Work Done ' <br /> .� <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Descr'be Material and Pro edure <br /> I hereby agree to comply with all laws and" regulations of, the San J aquin 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 s, <br /> WELL :DRI°LLERS 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 TOGROUTING AND A FINAL INSPECTION, <br /> SIGNED ; j Ci TITLEfi. <br /> (DRAW PLOT LAN ON REVERSE SIDE)V 01 <br /> } FO PARTIJENT USE ONLY j <br /> PHASE I " <br /> �-/--i - , <br /> APPLICATION ACCEPTED BY � �� .� --- ,'i DATE <br /> ADDITIONAL COMMENTS: i I <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY 7O' DATE INSPECTION BY ^,pa� DATE,S°-. <br /> Z7��Z_ <br /> E H 1426 Rev. 1-74 W 'e <br />