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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOR FT E USE: ' 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 GG <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. , /o <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is Aereby made to the San Joaquin Local Health District for a permit,to cgnstruct <br /> and/or^install the work herein. described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 18622 And the Rules and Regula ions of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONdNJ <br /> � ! � � CENSUS TRACT <br /> Owner's Name 9,49 ,=-- z --t� Phone /::;�- <br /> Address City - �� <br /> Contractor's Name License/YA a73hone4g�04 <br /> i <br /> TYPE OF WORK (Check): NEW WELL /C7--"DEEPEN / / RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTALLATION /,�/' PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> J <br /> DISTANCE TO NEAREST: SEPTIC TANK U SEWER LINES - PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OT1%R <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIV <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 Sea ' <br /> Cathodic Protection ✓Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical i Surface Seal Installed BX: T 2,27777=• . --. <br /> PUMP INSTALLATION; Contractor <br /> � L l <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL; Well Diameter Appro imate D h ' <br /> De i`b�,�a'�le al Procedure <br /> I hereby agree to comply with &lationjV of the San Joaquin Local Health Dlstri4dt , <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 w <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 AND A FINAL INSPECTION. <br /> SIGNED' If' TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY= Z-Z 3-7-�7 <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 7y <br /> ADDITIONAL COMMENTS; <br /> PHASE II GROUT. INSPECTION PHAS I/F NAL INSPECTION <br /> INSPECTION BY DATE INSP9CTION BY DATA, <br /> E H 1426 Rev. 1-74 <br />