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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. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued LA -3 <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 th Rules and Regulations of the San Joaquin Local Health District. <br /> 2_ �O <br /> JOB ADDRESS.'' = N IZA,t I CENSUS TRACT <br /> Owner's Name C,` -.�` Phone <br /> Address City - <br /> f <br /> Contractor's Name License Phone <br /> - t <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /_7 DESTRUCTION /7 <br /> PUMP- INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> 0ther` ( / - 7�1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES WIT PRIVY <br /> 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 Cable Tool Dia. of Well Excavation _ <br /> Domestic/private T Drilled Dia. of Well Casing <br /> ...ji—Domestic/public Driven, Gauge of Casing <br /> Irrigation ��Gravel Pack Depth of Grout Seal <br /> Cathodic Protection ,f Rotary Type of Grout <br /> Disposal 41..' 0 thef Other Information <br /> _Geophysical,,_ / Surface Seal Installed_By <br /> PUMP INSTALLATION: Contractor btt <br /> ajilty's.- J4 <br /> Type of Pumps H.P. Z <br /> PUMP REPLACEMENT: / / State Work Done p�. e4lil / <br /> PUMP .REPAIR: /' / State Work Done, <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Destri6e Material and3Procedure <br /> !k Aj <br /> I hereby agree to comply with\a:ll laW's 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 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 INSPECTIU . , <br /> SIGNED �f <br /> r <br /> P ON NE ERSE SIDE) <br /> FOR M71PARTMENJ USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE - <br /> ADDITIONAL COMMENTS: if o A ^p 0 <br /> PHASE II OROUT INSPECTION P I/ANAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> n177 2M <br /> E H 1426 Rev. • 1-74 � L <br />