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� Cs � 3 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> s'y FOF, OF'-ICE USE: I" 1601 E. Hazelton Ave. , Stockton, Calif. <br /> —� Telephone: f".09) 4f6-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT o• L <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7-,2Z- <br /> (Complete In Triplicate) <br /> Application is liereby 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 Rul��epp and Regul tions of the San Joaquin Local Health DistTiet. <br /> Na r rA o <br /> JOB ADDRESS/LOCATION ENSUS TRACT <br /> Ow►ier's Name ? Phone <br /> Address crj' <br /> City <br /> "f�2Cit' License hone <br /> ,�,`s Contractor's Name �--�— <br /> TYPE OF WORK (Check) : tJF:W WELL DEEPEN /� RECONDITIO /? DESTRUCTION-� <br /> PUMP INS LATION / / PUMP REPAIR /-7—pump REPLACEMENT /T �+ : <br /> Other <br /> 'ISTANCE TO NEAREST: SEPTIC TANK SEWER LINESIT PRIVY M C' <br /> SEWAGE DISPOSAL FIELD CESS OOL/SEEPAGE PI� OTHER � <br /> k . <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL s <br /> INTENDED USE TYPE OF WE CONSTRUCTION SPECIFICATIONS <br /> Industrial le Tool Dia. of Well Excavation/,Q.,,_ <br /> t :i�Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing r <br /> _-irrigation Gravel Pack Depth of Grout Seal or <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BX: <br /> PUMP INSTALLATION: Contractor <br /> Type of F,.mp H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> �r <br /> PUMP REPAIR: /% State Work Done <br /> DES-tKOCTION OF WELL: Well Liameter Approximate Depth <br /> Describe Material and Procedure <br /> ,i I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAIS <br /> after completion of my work on a new well. I will furnist, 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 rue to the best ? my knowledge and belief. I WILL FOR A GROUT INSPECTION <br /> PRIOR TO GKOU' NG ll A INr1i. PEi 10N.* <br /> SIGNED 1 1 TITLE <br /> DRAW PL PLAN ON REVERSE SIDE <br /> FM DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE 11 GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY � _ DA'n,', INSPECTION BY DATE <br /> 77 2M <br /> ,x <br /> F. H 1426 Rev. 1-74 <br /> �F <br />