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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E FOR'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br />[ ; <br /> Telephone: (209) 466-6781 l �� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete in Triplicate) <br /> Application is h+ereby 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 /> r County Ordinance No. '1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> k � <br /> JOB ADDRESS/LOCATION ��Zv� 3 (�/ C�c� /C` CENSUS TRACT <br /> I� Owner's Name zle, Phone <br /> Address <br /> City <br /> i <br /> Contractor's_=Name t ,,. •'y' License Phone -�E <br /> i y <br /> A <br />` TYPE OF WORK (Check) : NEW WELL / DEEPEN / / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATIONI .PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other l/ / t "� .-- <br /> DISTANCE TO NEAREST: SEPTIC �TANK SEWER LINES PIT PRIVY _ <br /> SEWAGE DISPOSAL IELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE ". PRIVATE DOMESTIC WELL ' _PXBLI.C_DOMESTI.C-WELL--�---� -� <br /> INTENDED USE TYPE OF WELL --�-- rWELL <br /> TYPE W <br /> Industrial Cable -Too-1--Dia,of We117Excavat1—on 0 <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation I . Gravel Pack Depth of Grout Seal o <br /> Cathodic Pr12- <br /> otection Rotary Type of Grout . <br /> Disposal r i Other Other Information <br /> Geophysical ^ -�, Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump _ r-- H.P. <br /> / <br /> PUMP REPLACEMENT: / / State Work Done ' { <br /> PUMP 'REPAIR: / '/ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of Joaquin Local Health District <br /> and the State of California pertaining to or regulating well "construction. Within FIFTEEN DA S <br /> after completion of my work oni a new well, I will furni-sh.t-he--San Joaqu"in Local Health District a I <br /> WELL DRILLERS REPORTof t wel and notify them before putting the well in use.. The above . <br /> information is true to the best of my knowle ge and belief. I WILL CALL FOR A GROUT INSPECTION. <br /> PRIOR TO GROUTING A FINAL I ------�—„ <br /> SIGNED <br /> TITLE LL' <br /> (D W PLOT'PLAN ON REVERSE SIDE) IL <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I :;12 jh <br /> APPLICATION ACCEPTED BY , DATE 7'r <br /> ADDITIONAL COMMENTS: ; <br /> PHASE II GROUT INSPECTION PHASE III/FINAL S ECT ON <br /> INSPECTION BY DATE INSPECTION BY E <br /> E. H 1426 Rev. 1-74 1/77 2M <br />