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."eo W GD t SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE SE: 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 l 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 an4 the Rules and Regulations of the San -Joaquin Local Health District. <br /> >5 <br /> .TOB ADDRESS/LOCATION - 4r� 44 e::-, Lsi CENSUS TRACT <br /> Owner's Name Phone ' <br /> t <br /> Address � � ~.,z�� City <br /> Contractor's Namo License <br /> 1 <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN '/7M RECONDITION f7 DESTRUCTION f 7 <br /> AL <br />' PUMP INSTLATION "I / PUMP REPAIR /7 PUMP REPLACEMENT f <br /> Other /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> t SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL" PUBLIC DOMESTIC WELL �I <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial a Cable Tool Dia. of Well Excavation <br /> :=k omestic/private i Drilled Dia. of Well Casing, <br /> _.Domestic/public i Driven Gauge of Casing <br /> Irrigation }i Gravel Pack- Depth of Grout Seal <br /> Cathodic Protection `i Rotary Type of Grout . <br /> Disposal ; Other Other Information -- y <br /> Geophysical Surface Seal Installed BY:S4 <br /> PUMP INSTALLATION: Contractor <br /> Type sof Pump H.P. / <br /> PUMP REPLACEMENT: / / -State Work Done .d� <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameters^ 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 knowled a anal f. I WILL CALL FOR A GROUT INSPECTION <br /> 'PRIOR TO GR G ANDA FINAL ECTI <br /> SIGNED <br /> W PVT PLAN ON REV SE SIDE <br /> FO EPARTMENT USE ONLY <br /> ' PHASE I <br /> APPLICATION ACCEPTED BY DATE f <br /> ADDITIONAL COMMENTS: <br /> PHASE II 'GROUT INSPECTION PHASE III .FINAL INSPECTION <br /> ' INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. . 1-74 2M <br />