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Ij <br /> �m.4 SAN JOAQUIN LOCAL HEALTH DISTRICT /�'0 <br /> r_,RwI fFUE USE. 1601 E. HazeltoA,Ave. , Stockton, Calif. <br /> Telephone (209) 466-6781 _ <br /> - APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. rJ <br /> THIS-PERMIT EXPIRES I YEA.R,FROM DATE ISSUED Date Issued at' , <br /> t (Complete In Triplicate) <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 /> r JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name fir► ,�., t Phone �� - -- <br /> Address 4t� h e�- '7;?- City <br /> Contractor's Name -- ecr..;d sA License # 1.S'F one <br /> TYPE OF WORK (Check) : NEW WELL/ / . DEEPEN "/ / RECONDITION /_/ DESTRUCTION /_7 <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 PIT OTHER <br /> 4# PROPERTY LINE - PRIVATE DOMESTIC WELL . PUBLIC DOMESTIC WELL <br /> INTENDED USE . TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial - Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> �C 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 /> V. r' <br /> PUMP INSTALLATION: Contractor_ <br /> Type of Pump.. _ iL� H.P. ' [5 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: jC/ State Work Done* g �. a �,. A,-J' Z^ <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> - -- <br /> Describe Material and Procedure <br /> - <br /> I hereby agree to comply with all laws and regulations of the Saiz Joaquin Local Health District <br /> and the State of California per-taining to or regulating well 'construct:ion. 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. k le ge elief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO TNG ANDA FINAL INSPECTION. <br /> SIGNED TLE _ <br /> (DZAW , I:OT PLAN ON RRnnE SIDE!T <br /> T -- - <br /> t FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: 1 <br /> PHASE II GROUT INSPECTION PHASE II/FINAL INSPECTION., <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> b/77 2M <br /> � E H 1426 Rev. . 1-74 _ _ , <br />