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a <br /> JOAQUIN LOCAL HEALTH DISTRIC9'"� <br /> FOR."OFFICE USE: L'� l6( Hazelton Ave. , Stockton,- Ca�_t. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7 <br /> (Complete In Triplicate) <br /> Application is hereby made to the� San Joaquin Local Health District for a per it .to construct <br /> and/or install the work herein described. This application is made in comp , a th San Joaquin <br /> County Ordinance No. 1862 and the' Rules and Regulations of -the San Joaquin H .a s Pict. <br /> JOB ADDRESS/LOCATION t3 {��v « ,� CENSUS TRACT <br /> Owner's Name %' e R Phone _ <br /> Address -Zo City ed= <br /> lContractorl's Name License <br /> # fW/Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL /- DEEPEN RECONDITION RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR � PUMP REPLACEMENT /-T <br /> Other /'J <br /> +DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY 'V <br /> SEWAGE DISPOSAL- FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE _ PRIVATEmDOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS O. <br /> Industrial ;Cable Tool Dia. of Well Excavation <br /> �'- 'Domestic/pxivate Drilled Dia. of Well Casing <br /> Domestic/public briven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout ' in <br /> Disposal Other Other Information <br /> 1 Geophysical Surface Seal Installed By: <br /> PUMP' INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work.Done <br /> a <br /> PUMP .REPAIR: / / State Work Done _fie pf <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 District <br /> L <br /> the State of California pertaining to or regulating wellm-construction. Within FIFTEEN DAYS <br /> F <br /> completion of my workmon 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.. The above <br /> information is true to the best of! my. knowledge and belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> ?RIOR TO GROUTING AND A FINAL INSPECTION., <br /> SIGNED MMiitj TITLE <br /> { W PLOT PLAN ON REVERSE SID <br /> PHASE I i FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> DATE -� <br />{ADDITIONAL COMMENTS: <br /> PHASE II R INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY s...a DATE <br /> E H 1426 Rev_ 1_7L _. ___ _ . 1677 ou <br />