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ma �: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFr,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> ZJ APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued <br /> (Complete In. Triplicate) 2--Z___Z/. <br /> Application is hereby made to the San Joaquin Local Health .District for a permit to construct <br /> a 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'"Y� CENSUS TRACT <br /> Owner's Name ' <br /> !L � Phone ' <br /> 'Address <br /> City ' . <br /> Contractor's Name � � o � ". License i <br /> kf" hone 2-W <br /> TYPETYPE OF WORK (Check) : NEW WELL -/7 DEEPEN ',/7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR -/? PUMP REPLACEMENT ./7 <br /> Other <br /> DISTANCE TO NEAREST: ' SEPTIC TANK � • SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESS�'OOL/SEEPAGE PTT OTHER <br /> PROPERTY LINE .. PRIVATE DOME5TIC WELL" PUBLIC DOME <br /> INTENDED USE STIC WELL <br /> TYrE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cabie Tool Dia. of Well Excavation t <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 e <br /> �--a <br /> Type of Pump y <br /> H.P. {s,� <br /> P UMP, REPLACEMENT: . <br /> /?C/ State Work Done <br /> PUMP '.REPAIR: %/ State Work Done <br /> DESTRUCTION_ OF WELL: Well. Diameter <br /> Describe Material and Procedure Approximate Depth <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 werll `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 1 <br /> information is true to thXTA'r .a m:y knowledge and nd belief. I WILL CALL FOR A GROUT INSPECTION f <br /> PRIOR TOG TNG 'AND A FIN S, C <br /> SIGNED � <br /> TIT .r <br /> (_ RAW PI,QT'PLAN ON VERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> TE <br /> ADDITIONAL COMMENTS: <br /> PHASE If GROUT I SPECTION ' PHA I. F INSPECTION' <br /> INSPECTION BY DATE INSPECTION $Y DATE <br /> _E_H 1426 Rev. 1-74 <br />