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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 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/LOCATION ��, -- -- � � �'�L <br /> CENSUS TRACT <br /> Owner's Name d `j� /L� �� (}�E) Phone <br /> Address / J ,* Q/V City *e,&L <br /> Contractor's Name License jk-ZJY�; 717Phone � <br /> 44 <br /> i <br /> TYPE OF WORK (Check): NEW WELL/Z DEEPEN / / RECONDITION /-7 DESTRUC /^7 <br /> PUMP INSTALLATION/—/ PUMP PAIR / / PUMP REPLACEMENT /7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC R NES0�= PIT PRIVY <br /> SEWAGE DISPOSAL F CE P001 /SEEPAGE PIT OTHER <br /> PROPERTY LINE - PR VATE D T WEL UBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL UC IFI ATIONS <br /> Industrial Cable Tool Dia. of Well Excava <br /> t.-',Domestic/private Drilled 4lia. of Well Casing ' _ <br /> Domestic/public Driven ,�Wo Gauge of Casing <br /> Irrigation Gravel Pack4 Depth of Grout Seal ITO <br /> Cathodic Protection !/Rotary '"'• Type of Grout <br /> Disposal Other Other Information <br /> Geophysical /f Surface Seal Installed By: C,6 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump •P• <br /> PUMP REPLACEMENT: j—/ State Work Done <br /> PUMP .REPAIR: / / State Work Done 1017,6 _ lriu <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth �B <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San J quip Loca ealth District <br /> and the State of California pertaining to or regulating well'construc ion. Wi h n FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaq in Loca ealth District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the-wel in us . The above <br /> information is true to the best of my knowledge and belief. I WILL CALL OR A G11,OUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW MOT PLAN ON REVERSE SIDE f ! <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> D LICA ION ACCEPTED JBY DATADDITIONAL COMMENTS: ' <br /> P <br /> N LELZ <br /> INSPECTION BY DATE fas Y DATE <br /> 717,, c x� - Gom c G 2l <br /> E H 1426 Rev. 1-74 ` <br />