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� <br /> SAN JOAQUIN LOCAL HEALTH- DISTRICT �~ <br /> FORCo OF CE USE: 1601. E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-678.1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 'Date Issued %.191_17WI <br /> (Complete In Triplicate) <br /> Application is hereby made to the Saz 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 andithe Rules and Regulations of the San Joaquin. Local Health District. <br /> JOB ADDRESS/LOCATION 2- CENSUS TRACT <br /> Owner's Name Phone <br /> Address City (� - <br /> Contractor's Name license # _ honed, <br /> .,mow b v$ <br /> TYPE OF WORK (Check) : NEW WELL _/ DEEPEN / `/ TRECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT- I <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 \Q <br /> Domestic/private' € Drilled Dia, of Well Casing <br /> 'Domesti"c./public Driven Gauge of Casing N <br /> Irrigation I Gravel Pack Depth of- Grout Seal F <br /> Cathodic Protection Rotary Type of Grout <br /> w Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: 'N <br /> PUMP INSTALLATION: Contractor �s Cao <br /> Type of Pump H.P. / <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: �!/ State Work Done .� <br /> t <br /> DESTRUCTION OF WELL:, Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all lawns 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 knowdge an ief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED LE y <br /> IZA ARA . I: PLANN RE SE SIRE) <br /> FtYK DEPARTMENT USE ONLY ; <br /> PHASE I i f <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: I <br /> PHASE II GROUT INS ECTION PHASE III/ . INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ., DATE '^ <br /> 4 <br /> E H 1426 Rev. 1-74 3/7 6 24 JJ <br />