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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOReOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: � (209) 466408.1 <br /> APPLICATION FOR WELL CONSTRUCTION'--OR PUMP PERMIT Permit No. <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. 1862 and the Rules and Regulations. of the San Joaquin Local Health District. <br /> 30B ADDRESS/LOCATION. )V.. r/,tTS CENSUS TRACT <br /> Owner's Name -D <br /> Dias _TA? Phone <br /> Address - , <br /> city <br /> t <br /> Contractor's Name �4-_/1�>9G��9DD License Phone lob: fy�g� <br /> TYPE OF WORK (Check): NEW WELL/DEEPEN /_7 RECONDITION 47 DESTRUCTION /'j , . { <br /> PUMP INSTALLATION LT7 `PUMP REPAIR /_7 PUMP, REPLACEMENT -#/? <br /> Other-L-7 _.._ - <br /> DIST C16 � <br /> DISTANCE ,TO;NEAREST: SEPTIC TANK ,/75 _ SEWER LINES _-L6,0 PIT PRIVY <br /> u { W 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 Gable Tool. Dia. of?Well Excavation f <br /> omestic/private Drilled Dia. of <br /> Yell 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 BY: <br /> PUMP INSTALLATIONS Contractor <br /> Type of Pump H.P.44 <br /> PUMP REPLACEHENT:,A;��4 / `State Work Done , <br /> PUMP :REPAIR: State Work Done.. <br /> ES•TRUCTION OF.. WEI;L: Wel).'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. 1 <br /> WELL DRILLERS REPORT of the well and notify them before .putting the-.well in.use.., 'The above <br /> information 4s true to the-best -of my knowledge and belief. I WILL CAL FOR AGROUT INSPECTION <br /> PRIOR T0. 16ROUTTNG AND A,.FINAL INSP :CTIO <br /> SIGNED ,4211L4 . 4r. TITLE <br /> RAW 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 INSPECTIO PHASE III FINAL INSPECTION <br /> INSPECTION By _f"� DATE INSPECTION BY _ DATE s <br /> E H 1426 Rev. 1-74 { <br />