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? SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO&,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. T7—//39f <br /> I Telephone: (209) 466-6781- <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT ERPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> j (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 /> r <br /> JOB ADDRESS/LOCATION <br /> 7SfG !? `Jf CENSUS TRACT <br /> Owner's Name /���^/� Phone <br /> Address / `�6 2r/ 471 . �/ UCS/ City 1F <br /> Contractor's Name (xli vim. 2/�f�f�q License # F GJ G(/z Phone <br /> f <br /> TYPE OF 'WORK (Check): NEW WELL DEEPEN /-7 RECONDITION /7 DESTRUCTION f7 <br /> PUMP INSTALLATION REPAIR '/-7 PUMP REPLACEMENT /7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIClTANK 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 .6 X Cable Tool' Dia. of Well Excavation &I k, <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public`_c Driven Gauge of Casing $I3 VI <br /> Irrigation Gravel Pack Depth of Grout Seal \ A <br /> Cathodic Protectl'on Rotary Type of Grout I,CU <br /> Disposal t Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: .. / / State Work Done <br /> PUMPiREPAIR: /7 _State Work Done <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 /> and the State of Californiapertaining to or.regulating,well'construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish.rhe 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 beat of my knowledge and belief. I WILL CALL F6R A GROUT INSPECTION . <br /> PRIOR TO OUTI G D A FINAL:INSPECTION. <br /> SIGNED TITLE <br /> V (DRAW PLOT PLAN ON REVERSE SIDE <br /> J <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> t <br /> A,�jfICATION ACCEPTED BY / DATE <br /> IDNAL COMMENTS: � i 0 <br /> PHASE II ROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION SYL�- DATE INSPECTION BY DATE l <br /> E H 1426 Rev. 1-74 V./oK 0m, <br />