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' v SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> LFFF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 ,y173 y� <br /> THIS PERMIT EXPIRESkl YEAR FROM DATE ISSUED Date Issued 1)) <br /> I (Complete In Triplicate) $ -z plicationis'is hereby made to the San Joaquin Local Health District, for a permit to construct <br /> d/or install the,work herein described. This application is made in compliance with San Joaquin <br /> ..County Ordinance No.11862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> -JOB ADDRESS/LOCATIONAl p �{ <br /> CENSUS TRACT <br />!. Owner's Name Phone <br /> •— <br /> City <br /> f Contractor's Name y J License # �1/ 0 Phone <br /> TYPE OF WORK (Check) NEW;TnIELL / / DEEPEN %/ .�RECONDITION /? DESTRUCTION /-7 <br /> ;PUMP INSTALLATION / / PUMP REPAIR/ / P <br /> OtUMP REPLACEMENT <br />':'DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY "* <br /> 1 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED' USE TYPE OF WELL W <br /> Industrial V. CONSTRUCTION SPECIFICATIONS Q, <br /> Cable Tool Dia.Aof Well Excavation <br /> Domestic/private Drilled Dia. "of"Well Casing . <br /> Domestic/public Driven k Gauge of Casing <br /> Irrigation <br /> Gravel Pack Depth of.-Grout Seal Ni <br /> Cathodic Protection ,mss=Rotary, Atj Type-, f ,Grout 1 � <br /> Disposal Other Other Information: a <br /> Geophysical 'Surface S <br /> eat Installed B : <br />:PUMP INSTALLATION: Contractor <br /> Type: of Pump f, H.P. <br />`PUMP REPLACEMENT: , gl- State-Work Doneijze <br />'PUMP :REPAIR: s <br /> State Work Done a. <br /> . _ V <br /> IbES•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby. agree to comply with all laws dnnd regulations of the San Joaquin Local Health District <br /> and the State of California pertaining t0---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-besi of my knowledge and belief. I WILL CALL F R A GROUT INSPECTION r <br /> PRIOR TO GRO NG AND A IN INSPECTION, <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> � <br /> APPLICATION ACCEPTED BY <br /> DATE <br /> ADDITIONAL COMMENTS:"' <br /> PHASE II QRQUT INSPECTION PHAS III •NAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY <br /> } _.( DATE �` <br /> E H 1426 Rev. 1-7L 1 177 ens: <br />