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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. ,-17�/`f d <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssuedT, <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 /> �/� i CENSUS TRACT <br /> i JOB ADDRESS/LOCATION a-i '�� �o ��� '�. �_ _ <br /> , G <br /> Owner's Name - Phone <br /> Address Zf z C-j lair^ City <br /> Contractor's Name - License+ , Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ I DEEPEN/ / RECONDITION /• / DESTRUCTION-/7— <br /> PUMP <br /> ESTRUCTION /7—PUMP INSTALLATION I I PUMP REPAIR / I 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 - PRIVAT�E�DOMESTIC WELL- PUBLIC_DOMESTIC WELL <br /> INTENDED USE TYPg-.OF WELD .✓'" I • CONSTRUCTION SPECIFICATIONS � . <br /> Industrial _ _CabI6 Tool Dia. of Well Excavation <br /> Domestic/private "'Drilled Dia. o Wel Casing <br /> Domestic/public Driven Gaugd-of-tCas.fng <br /> Irrigation Gravel Pack Deptht of GroutlSeal <br /> Cathodic Pr-o'tection Rotary Type <br /> Type of Grout <br /> Disposal Other._ ` _; 6thei Info on <br /> Geophysical Surfacd-Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump A H.P. ji;- <br /> 2����v <br /> PUMP REPLACEMENT J / State Work Done <br /> PUMP .REPAIR: / / State Work Done N oil I <br /> DESTRUCTION OF WELL: C4We11 iametier .:�. - -»�.. Ap.pyroximate Depth <br /> vDeacr lie 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. wel.l in use. The above <br /> information is true to th best of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO G AND A UL INSPECTION. <br /> SIGNED TITLE 6-VVfl ,al <br /> I3 PLT PLAN 'ON RE FRSE SIDE�� <br /> FOR DE ARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION R <br /> INSPECTION BY DATE INSPECTION BY DATE — <br /> 3 " <br /> E H 1426 Rev. . 1-74 <br /> . <br />