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v SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. cls - <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. / <br /> i' <br /> THIS PERMIT EXPIRES 1 YEAR--FROM DATE ISSUED Date Issued <br /> (C I In <br /> Application is hereby made to the San Joaquin eLocal rHealth tDistrict for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joequin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ,' <br /> CENSUS TRACT <br /> Owner's Name \ Q Phone <br /> l <br /> Address ��� <br /> City <br /> Contractor's Name -,P7 Licen ���Phone j V�_ <br /> t' <br /> TYPE. OF WORK (Check) : NEW WELL I I DEEPEN%/ RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY iWl <br /> —S-EWA-GE CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE- PRIVATE.DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE - 'TYPE-1OF' "` <br /> WELL• .r CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable'-Tool Dia, of Well Excavation <br /> Domestic/private Drilled' Dia, of Well Casing <br /> Domestic/public 'Driven j Gauge of Casing <br /> Irrigation : Gravef PackDepth of Grout Seal <br /> Cathodic~ ProtectionRotary ' Type of Grout <br /> Disposal OtherOther Information <br /> Geophysical _ { Surface Seal Ifnstalle`d B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> I <br /> PUMP -REPAIR: /% State Work Done <br /> F <br /> DESTRUCTION OF WELL: Well Diameter Ce A proximate= Depth 0 <br /> Descig4be Matrial and Procedure <br /> I hereby agree to comply with all -law and regulations of the Sart Joaqu'n Loc - Heal'th District. <br /> and the State of California pertaining to or regulating well. '-construction. WithinvFIFTEEN DAYS f <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. jhe above <br /> information is true to the best of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO VTING D A FINAL--INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) 1 <br /> FO D ARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY � � DATE <br /> ADDITIONAL COMMENTS: ♦Y'r `/ �x rc c�. 0 <x�u� �iy, <br /> PHASE II 'GROUT INSPECTION "'PHASE III/PIN INSPECTIO <br /> INSPECTION BY �- DATE INSPECTION BY 9E. DATE /( 7 <br /> 177 2M <br /> E H 1426 Rev. 1774 _ _ � , <br />