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JOAQUIN LOCAL HEALTH DTSTRI <br /> FoR OFFICE USE: 16 E. Hazelton Ave. , Stockton, Ca..__I:. <br /> Telephone:. (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PU11P PE1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM. DATE ISSUED Date IssuedzV <br /> (Complete In Triplicate) <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 Joaquit <br /> 'County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local. Health District. <br /> JOB ADDRESS/LOCATION q Ll -21 CENSUS TRACT <br /> 'Owner's Name Phone <br /> Address CityCtt..�. <br /> Contxaetor's Name -. , � License # <br /> 'I-hone � . <br /> ;TYPE OF WORK (Check): NEW WELL / / DEEPEN '/ / RECONDITION /_� DESTRUCTION /_7 <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 <br /> i PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> k Industrial Cable Tool Dia. of Well. Excavation <br /> G >L-Domestic/private Drilled Dia. of Well. Casing <br /> Domestic/publ.ic Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> ,PUMP INSTALLATION: Contractor L ,' <br /> Type of Pump h f` <br /> H.P. <br /> Z' <br /> V <br /> SPUMP REPLACEMENT: j_/ State Work Done <br /> PUMP :REPAIR: State Work Done <br /> . 41 <br /> R 4 ? e. <br /> ES•TRUCTION 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 /> -and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> i after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them pre putting.the..well in use. The above <br /> information is true to the best 6f mv�knowXed� anrJ, elief, I WILL C�;LL FOR A GROUT INSPECTION <br /> PRIOR TO GNUING .AND A FINAL INSP CrIO �' t <br /> SIGNED `� Fcx <br /> ter.. s TITLE <br /> 2-w- PLOT. PLAN ON RE RSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> ;APPLICATION ACCEPTED DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/ NAL INSPECT1 N <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> Y <br /> i E H 1426 Rev. 1-74 <br />