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it <br /> �rQ A SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFF 1~CE USE: '! 1601 E. Hazelton Ave. , Stockton, Calif. <br /> !I Telephone : (209) 466-6781 / <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 'T7� SSD <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. . 1862and the Rules and Regulations of the San Joaquin Local Health District. <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION - e, �� _ . am <br /> _ � - — <br /> Owner's Name �I4.4 Phone <br /> 9 <br /> Address � � City <br /> Contractor's Name License # &. _771phone Al�.� <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / % RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR , / PUMP REPLACEMENT /7 <br /> 0�'ther / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESq . PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED` USE !i TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industria. !� Cable Tool D"ia, of Well Excavation p� <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 �i Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> ii <br /> I� PUMP REPLACEMENT: / / State Work Done <br />{ PUMP REPAIR: / State Work Done ' <br />` DES-TRUCTION OF WELL: Well Diameter " Approximate Depth <br /> Describe Material and Procedure <br /> I! <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 we 11 'construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, T will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of1the 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 OU ING AND Ai FINAL INS <br /> . 0. ,TLE <br /> SIGNED i <br /> p (D P LAN ON ETRSE SIDE) <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> � APPLICATION ACCEPTED BY. DATE <br /> ADDITIONAL COMMENTS: �� <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECT ON <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> r <br /> N. <br /> . _ a <br /> E H 1426 Rev. 1-74 -1 <br />