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F 1JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOk'OFFICE USE; 160 �. Hazelton Ave. , ,Stockton, Cali <br /> Telephone; (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PE ,_ T� hermit l�ci��-9�3� <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is 4ereby 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 Jaaq.uit <br /> County. Ordinance No. 1862 and the, Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION p CENSUS TRACT <br /> Owner's Namea J2 ¢ <br /> `� I 11 � ,�e`I f l''y � Phone- - 3 <br /> Address .� ,KD Q , City '. -e <br /> Contractor's Name r f .License # 30?02 Phone .72--&S'948 r <br /> TYPE OF WORK (Check) : . NEW WELL/? DEEPEN /-7 RECONDITION /-7 DESTRUCTION /—T <br /> PUMP INSTALLATION /. PUMP REPAIR / / PUMP REPLACEMENT / . <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER � � Q <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL C <br /> INTENDED USE TYPE OF. .WELL :CONSTRUCTION `SPECIFICATIONS <br /> Industrial. Cable Tool Dia. of Well Excavation_ . <br /> Domestic/private Drilled Dia. of.Well Casing s <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation" Gravel-Pack .Depth of Grout Sea-I-,- <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: _ <br /> PUMP INSTALLATION: Contractor 3 <br /> Type of Pump 4II.P. p <br /> PUMP REPLACEMENT State Work Donery ° <br /> PUMP :REPAIR: / / State Work Don <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 the San Joaquin Local Health strict <br /> and the State of California pertaining to or regulating well construction. Within FTFTEEN'DAYS <br /> after completion of my work on a new well, I will furnish the Sao, Joaquin Local Health Di.strict.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 best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTIOP <br /> PRIOR TO GR TING -AND A F NAL INSPECTION. <br /> SIGNED TITLE aez�—z <br /> s . <br /> (DRAW PLOT PLAN ON REVERSE SIDE)- <br /> FOP, DEP MERIT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE AOX - <br /> ADDITIONAL COMMENTS. <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION .BY DATE INSPECTION BY DATE % <br /> E H .1426 Rev. 1-74 <br />