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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOh� 16 <br /> �OFFICE USE: ' <br /> 01 E. Hazelton Ave. , Stockton, Calif. <br /> k 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 shade to the San Joaquin Local Health District for a permit to construct <br /> and/or install the worts herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San oaquin Local Health District. - <br /> JOB ADDRESS/LOCATION Joh <br /> '�' s'L' DvSUS TRACT 2Z7 380--0 q <br />,rOwner's Name <br /> � �' Phone <br /> r J I <br /> Address' �a <br /> City ' f.'ScAka j f <br /> Contractor's Name _ License # � Phone ' <br /> TYPE OF woRx <br /> (Check): NEW WELL /_7 DEEPEN '_i RECONDITION L7DESTRUCTION f7 <br /> PUMP INSTALLATION -/ / PUMP REPAIR ', <br /> Other /% PUMP REPLACEMENT /7 <br />.r <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> "E PROPERTY LINE PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED' USE TYPE .OF WELL v CONSTRUCTION SPECIFICATIONS <br /> Indus trial•: .NA <br /> Cable Tool : Dia. of Well Excavation <br /> Dor4estic/privateer :.,. Drilled Dia. of Well Casing <br /> Doftstic/public' Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth-.oV Grout Seal <br /> Cathodic Protection Rotary Type�/bf,Grout <br /> Disposal Other f Other I�iforisation <br /> Geophysical t Surface Seal Installed By: d <br />-PUMP INSTALLATION: Contractor _ ti <br /> Type of Pump <br /> PUMP REPLACEMENT: • State Work Done <br /> PUMP (REPAIR: j27State Work Done <br /> DE&T.IUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply with al•1 lawns and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or reg ula.ting, 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 puttingthe..we13- in-use.... .The above <br /> information is true to the•bestjof my.-knowledge and belief. I WILL CALL 'FOR A GROUT INSPECTION <br /> SIGN TO GROUT G AND -FIN IPISPECTION.� <br /> SIGNED <br /> TITLE - <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> P,PP IL�CATION ACCEPTED BY DATE <br /> 4DDITIONAL COMMENTS: V zf <br /> ; r PHASE I LAMINSPECTION P II N INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> EL H1426 Rev. 1-74 <br />