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(B �� ►�fSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO _ raF t > t <br /> F OFFICE E: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;y <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 /> i <br /> JOB ADDRESS/LOCATION S CQtz,in2 / CENSUS TRACT <br /> Owne r's Name 011 M 9I~" Phone <br /> Address x.., ' City <br /> s � <br /> Contractor's Name License # 2Phone L G G <br /> OK <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN f / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTLATION PUMP REPAIR PUMP REPLACEMENT /� <br /> AL <br /> Other / / -- <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 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public 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 .� <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMPS f C/ State Work Done �f <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 California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> 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 before putting the well in use. The above <br /> information is true to the best of my wle and b lief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUT NG AND A FINAL I N. <br /> SIGNED C & TLE ,,., <br /> ( LOT P AN ON REV SE SIDE) <br /> OR DEPARTMENT USE ONLY # <br /> PHASE I [�_ <br /> APPLICATION ACCEPTED BY DATE �—g 1 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT-INSPECTION PHASE /Fl AL IN`SPEC IO <br /> INSPECTION BY DATE INSPECTION BY ATE <br /> 6'77 _ 2M <br /> E H 1426 Rev. , 1-74 <br />