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JbAQUlN L+ CAL HEAI�"THDI TRIC <br /> FOROFFICE USE; Hazelton;Ave. , Stockton, Calif <br /> Telephone: (209) x+66-6781 O <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP P T <br /> [PeiNo. 7E;-1,1q►fF <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued (-����� <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS,/LOCATION CENSUS TRACT <br /> ' I <br /> Owner's Name Ly., C; <br /> �� ! Phone <br /> Address W City S'� 4,,✓ <br /> Contractor's Name ; - License Phone ' t <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN -/_7 RECONDITION /? DESTRUCTION /_ <br /> PUMP INSTALLATION I / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY , <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> ! 'INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable -Tool Dia. of Well Excavation 4 <br /> Domestic/private Drilled Dia. of Well. Casing . •d <br /> Domestic/public Driven Gauge of Casing C,j <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 <br /> Type of Pump H.P. �\ <br /> PUMP REPLACEMENT: Z/ State Work Done r <br /> PUMP :REPAIR: /7 State Work Done <br /> 2ES•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 /> after .completion of my work on a naw--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 /> PRIOR TO GROUTING AVP A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY; DATE <br /> PHASE II OUT ANSPECTION PHASE II ./FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426- <br /> .:. Rev. I-74 <br />