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�- SAN JOAQUIN LOCAL HEALTH DISTRICT - - <br /> FORrOFFICE USE. 1601 E. Hazelton Ave. , Stockton, Calif. <br />' Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date issued _s�7 <br /> (Complete In Triplicate} <br /> Application is hereby made to the San Joaquin Local Health District fora 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 /> JOB ADDRES S AOCATION tl I CL <br /> CENSUS TRACT <br /> Owner's Name FE <br /> Phone cf <br /> Address '� aj/ � - <br /> City 6,Se_-,Q ZOL.,7 <br /> Contractor'sName <br /> z _ License a �iy phone g �_ <br /> TYPE OF`WORK (Check):. NEW WELL, /_7, DEEPEN J RECONDITION Fl DESTRUCTION - <br /> PUMP INSTALLATION / PUMP REPAIR <br /> Other / / PUMP REPLACEMENTf% <br /> r /% <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> � � SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> pRflpERTY 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 � � Drilled <br /> Domestic Dia. of Well Casing <br /> /public Driven Gauge of Casing .t <br /> Irrigation _ Gravel PackDepth of Grout Seal <br /> Cathodic Protection y i , , y'"Type of Grout <br /> _`__,wDispOther <br /> —Disposal Other Information <br /> Geophysical Surface Seal Installed B ; <br /> t <br /> PUMP INSTALLATION: Contractor r <br /> Type of Pump, <br /> j �. _. _.. H.P. <br /> PUMP REPLACEMENT: / / State Work Done ~ <br /> PUMP REPAIR: - " ­/-T-State Work Done <br /> E&TRUCTION OF WELL: Well Diameter l �i <br /> Describe Material and Procedure Approximate Depth y <br /> I hereby agree to comply with all laws and it <br /> 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.. <br /> above <br /> information is true to the best-of my knowledge and belief. I WILL CALL FRA GROUT eIN PECTION <br /> PRIOR TO GR TING AND FI AL INSPECTION. <br /> SIGNED <br /> IT <br /> DRAW PLOT PLAN ON REVERSTE SLE <br /> IDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> ATION ACCEPTED BY r4, <br /> ADDITIONAL COMMENTS: DATE Z T- <br /> ROUT INSPECT P IN <br /> AL INSPECT <br /> INSPECTION By DATE <br /> INSPECTIO DATE <br /> E H 1426 Rev. 1-74 r <br />