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L� 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 6-17�d <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 Y_'!�� �1 _,. .,,_. Phone <br /> Address <br /> City .f r�r e <br /> Contractor's Name License, . " Phone. JT-7 #��t <br /> TYPE OF WORK (Check) : NEW WELL PK DEEPEN -/-7 RECONDITION /-7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR /-7—PUMP REPLACEMENT f f <br /> Other / I <br /> DISTANCE TO NEAREST: SEPTIC TANKO SEWER LINES /,00 PIT PRIVY /d O <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL ' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ^� Cable Tool Dia. of Well Excavation <br /> A�-- Domestic/private Drilled Dia. of Well Casing N <br /> Domestic/public Driven Gauge of Casing _f -__„_.� <br /> Irrigation Gravel Pack Depth of Grout Seal el ' <br /> Cathodic Protection Rotary Type of Grout �. „ <br /> Disposal , Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: J / State Work Done <br /> PUMP 'REPAIR: /-7 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 ANDA INALINSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED BY DATE _ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION F PHASE III FINAL INSPECTION <br /> INSPECTION BY -C DATE -/X'1� INSPECTION BY DATE ,�-/,/�•7� <br /> lE H 1426 Rev. 1-74 1-74 2M <br />