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yf.. <br /> } '� � SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Nop� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued X7/7 <br /> (Complete In Triplicate) <br /> Application is hereby made °to the San Joaquin Local Health District for a permit to construct i <br /> and/or install the work, herein described. This application is "made in compliance with San Joaquin j <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> 1 <br /> JOB ADDRESS/LOCATION ID.S� CENSUS TRACT <br /> Owner's Name Phone <br /> F <br /> Address City <br /> +° Contractor's License <br /> Contractor's Name ®. s® L � �: � License #No.27666a Phone <br /> TYPE OF WORK (Check): NEW WELL /- DEEPEN '/ / RECONDITION / / DESTRUCTION /—T <br /> PUMP INSTALLATION '/ /• PUMP REPAIR/ / PUMP REPLACEMENT / - <br /> Other / / ` <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY i <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE ..- PRIVATE •DOMESTIC WELL PUBLIC DOMESTIC WELL 4, 1 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS N <br /> Industrial Cable Toolt W Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well .Casing � i <br /> Gid <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 /> i <br /> PUMP INSTALLATION: Contractor ,A <br /> Type of Pump H.P., <br /> PUMP REPLACEMENT: /State Work Done <br /> PUMP .REPAIR: % / State Work Done, _ <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure I <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'knowledg and .belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIER TO.29ZEING ED A F I N SO E CjjZ N. <br /> SIGNED TITLE <br /> ZZ <br /> !",(DRAW:. T PLAN"ON RE FRSE SIA) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 3/ .7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I FINAL INSPECTION ; <br /> INSPECTION BY DATE INSPECTION BY DATE l/— --7 7 i <br /> � 2M <br /> E H 1426 Rev. 1-74 �3� { <br />