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~_ m FIT SAN JOAQUIN LOCAL HEALTH.DISTRICT <br /> FOF OFFI E USE: 1,601. E. -Hazelton Ave,, Stockton, Calif. <br /> a Telephone: (209)j466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. `]_1 $ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete InTriplicate) <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 District. <br /> JOB ADDRESS/LOCATION �-� 1 � _ CENSUS TRACT <br /> Owner's Name , Phone <br /> Address I� � 291,,At),y is City �T <br /> Contractor's Name. License # -2;1*'PPhone <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN.-/—/ RECONDITION /_7 DESTRUCTION % f <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES, PIT PRIVY <br /> SEWAGE DISPOSAL FIELD ' CESSPOOL/SEEPAGE PITT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICA'T'IONS �. <br /> Industrial Cable Toole 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 /> PUMP INSTALLATION: Contractor . <br /> Type of Pump A.P. I <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP _REPAIR: / / State Work Done { <br /> t�- <br /> i <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''codstruction. 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 INSPECTION j <br /> PRIOR TO GROUTING AND A FINAL INSPE <br /> SIGNED ITLE )-4 ; <br /> (D PAN ON 'SE SIDE) F <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY '� DATE / <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P /F AL INSPECTION_ , <br /> INSPECTION BY %1/ DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-747 <br />