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SAN JOAQUIN LOCAL HEALTH DISTRICT ]�c� <br />` FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. fY <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 <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. 2862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONZ �, A. + w ,� CENSUS TRACT <br /> Owner's Name C_L� - TT C0 .„. .—.,----- Phonelsri —�rtr <br /> Address �6 Z, �. t.�'a-� T[.� City s- <br /> 'Contractor's Name ' <br /> � � �� .. License #3�•�7SX°'phone <br /> TYPE OF WORK (Check) :- ..NEW WELL/ / DEEPEN/ / RECONDITION / / DESTRUCTION /- <br /> PUMP INSTALLATION PUMP' REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -= PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE f TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> -i=---I-ndustrial Cab � Tool D a of We l`Excavafion�` -- s <br /> —Zs <br /> estic/privateDrilled 'Dia' of Well Casiniz <br /> mestic ub1ic Driven Gau a of Casing <br /> /P g <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal ,. ,. Othe-t, P Other Information <br /> Geophysical i ' Surface Seal Installed By: <br /> PUMP INSTALLATION: Contracto-r;s, � <br /> Type of, Pump j H.P. <br /> PUMP REPLACEMENT: / / StateLWork Done <br /> PUMP .REPAIR: / _/ 5_ta e? Work Done <br /> 4-=_.. / <br /> PESTRUCTIONOF :WEIA. ,-:Well Diameter 0& P Approximate Depth <br /> bescribe Material and Procedure <br /> I hereby agree to- comply w liall laws and regulations of the 'San Joaquin Local Health District <br /> and the, State._ol-California pertaining to or regulating well'construction. Within FIFTEEN DAYS <br /> after c mple,tion of, my work on—a=new well, I will furnish the San Joaquin Local Health District a <br /> WELL-DRILURS"REPORT ofithe well and notify them before puttingthe..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 GROUTIN AN A;F;INAL INSPECTION. <br /> SIGNED AJ& "" TITLE , <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br />` PHASE I <br /> APPLICATION ACCEPTED BY !/ '/\ DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA /FIN INSPECTI 1 . <br /> INSPECTION BY ' DATE INSPECTION BYDATE <br /> ��-- <br /> 7 <br /> 4 <br /> E H 1426 Rev. 2-74 <br />