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40( <br /> F FOE 9 SAN JOAQUIN LOCAL -HEALTH. DISTRICT <br /> FI 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 <br /> (Complete <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 /> k JOB ADDRESS/LOCATION .�`a Q 40y� AX— CENSUS TRACT _ <br /> Owner's Name I Phone <br /> f <br /> Address sZ d S�/f <br /> � City <br /> .Contractor's Name � License # Phone <br /> TYPE OF WORK (Check) : NEW WELL/_7 DEEPEN '/ / RECONDITION /_% DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR F <br /> ._ /�' PUMP REPLACEMENT /� <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTICITANK SEWER LINES PIT 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 Drilled Dia. of Well Casing <br /> -Domesticjpubli_C Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection - } Rotary Type of Grout <br /> ,—Disposalm. Other Other Information,* <br /> GeophysicalSurface Seal Installed B <br /> PUMP.-INSTAi.LATION: Contractor �j Q 4 <br /> w Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP .REPAIRA ; <br /> 4 / _State Work.Done Q <br /> DES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with.1a11 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 ori 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..wel1 in use. The above <br /> information is true to the-best of m knowledge d belief. I WILL .CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR UTING D ,A FINAL IO <br /> SIGNED --TITLE <br /> d � <br /> i RAPAN ON FRSE SIDE} `' -`�'"? �. <br /> FOR DEPARTMENT USE ONLY <br /> PHAS&. I <br /> APPLICATION ACCEPTED BY <br /> DATE 3jh� <br /> ADDITIONAL COMMENTS: V <br /> PHASE II GROUT IN ECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE '- r <br /> E H 1426 Rev. 3/76 2M <br />