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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E.- Hazelton Ave. ,- Stockton, Calif. <br /> Telephone: (209) 466-6781 .i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. yJ <br /> -,3 Pira' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssuedS_Z - 7cf <br /> (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 Ru3es and Regulations of the San Joaquin Local Health District. ' <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone <br /> Address - fi city.. <br /> �I <br /> Contractor's Name -License Phone d �3&, <br /> TYPE OF WORK (Check): NEW WELL/_7 DEEPERECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION / PUMP REPAIR /� PUMP REPLACEMENT %f <br /> Other / / T/ate T Qo_.l:IES <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWERjLINES 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 rf .1 CONSTRUCTION SPECIFICATIONS Q. <br /> f ¢ Industrial Z77Cable Tool Dia. •f Well Excavation <br /> omestic/private Drilled Dia.'of�Well Casing <br /> Domestic/public Driven Gauge of Casing a <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:�' C�' R <br /> PUMP INSTALLATION: Contractor t ; <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'REPAIR; /7 State Work Done <br /> E&TRUCTION 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 construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquiu.Local Health District a <br /> WELL DRILLERS REPORT of the well and notif them before " <br /> y putting the..we11 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 TO GROU ING DF SPECT ION.. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> 1 FOR DEPARTMENT USE ONLY <br /> t PRASE I 1 <br /> APPLICATION ACCEPTED BY�T � DATES <br /> ADDITIONAL COMMEN ; <br /> , t <br /> HA II G U INSPECTIO PHASE"/F IN"NSPECTM <br /> INSPECTION BY DATE INSPECTION B TE <br /> 1426 Rev. I-74 p 1-74 2M <br />