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[� yG � SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 13 Telephone : (209) 466-6781 <br /> APPLICATION FOR FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUES] Date Issued `A_ 7 <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 — CENSUS TRACT <br /> Owner's Name <br /> Address City <br /> Contractor's Name ? + s icense # Phone , <br /> - i <br /> TYPE OF WORK (Check) : NEW WELL /PDEEPEN / / RECONDITION / J DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK M! SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD /XI* CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL O <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <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 B3 <br /> PUMP INSTALLATION: Contractor a, <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done Y <br /> PUMP .REPAIR: /% State Work Done__ Gi �A'Ndaw <br /> DESTRUCTION OF WELL: Well. Diameter Approximate Depth (.CA//f <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health Distrir"t <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DA 'S <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health Distri(t 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 G UTING ANDt AL INSPECTION_ <br /> SIGNED &I yj TITLE VJ� <br /> W PLOT PLAN ON VERSE SIDE) <br /> PHASE I <br /> FOR DEPARTMENTUSE ONLY <br /> /�y <br /> APPLICATION ACCEPTED BDATE � � <br /> ADDITIONAL COMMENTS: <br /> PHASE GROU INSPECTION PHASE/TI;/FININSPECTION <br /> INSPECTION BY DATE z-7� INSPECTION BY DATE 3- -z E;-7 9' <br /> E H 1426 Rev. • 1-74 Z`z /Y .4) .7 _ 2973 <br />