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JOAQUIN LOCAL Fi.EALTH-DISTRICT � <br /> FOReOFFICE USE: ZSAN <br /> 1 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 Rules and Regulations of: the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION1 9�f ?�J „• . �,a �� .,lr:f — �f risl�, /cENsus TRACT <br /> Owner's Name r y- PhoneL <br /> Address <br /> City <br /> ' f <br /> YContractor:s Name-, - License# o 3 Phone <br /> TYPE OF WORK (Check): NEW WELL/W DEEPEN '/7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION /7-pump REPAIR /7 PUMP REPLACEMENT f 7 <br /> Other /7 <br /> DISTANCE TO NEAREST: +SEPTIC TANK ICO ' SEWER LINES -- PIT PRIVY <br /> X SEWAGE DISPOSAL FIELD /BO CESSPOOL/SEEPAGE PIT. -- OTHER -- <br /> PROPERTY LINE W)PRIVATE DOMESTIC WELL '_ PUBLICDOMESTIC WELL �- <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 2� <br /> y Domestic/private ' Drilled Dia. of`-Well Casing <br /> -_ Domestic/public Driven Gauge of Casing I� c <br /> Irrigation , Gravel Pack Depth of Grout Seal S,d -- -rfl <br /> Cathodic Protection Rotary Type, of Grout <br /> Disposal Other Other Information k5lab <br /> Geophysical - ,,..Surface eat Installed B <br /> PUMP INSTALLATION: ' <br /> NSTALLATION Contractor <br /> Type of Pump A.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP ,.REPAIR: L7 ` State Work Done <br /> ES;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 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 <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> RAW PL T PLANON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I � <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COS_: - <br /> ROUT INSPECTION II INAL INSPECTION <br /> INSPECTION Y DATE INSPECT DATE - - <br /> E H 1426 Rev. 1-74 z <br />