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la. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO> I-OFFICE USE V .N 1601 E. Hazelton Ave. , Stockton, Calif. <br /> li Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> !! THIS PERMIT EXPIRES 1- YEAR- FROM DATE ISSUED Date Issued �� <br /> INS (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 /> y County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONQd-, � / Qm� � , CENSUS TRACT <br /> Ham„ „P. .. <br /> Owner's Name I� Phone <br /> Address o M e da dg rkz r�u P� - City <br /> Contractor's Name '. License # f6 Phone 6' <br /> IN <br /> TYPE OF WORK (Check): NEW WELL '/_V� DEEPEN '17 RECONDITION /7 DESTRUCTION /7 <br /> + PUMP .INSTALLATION / / PUMP REPAIR /r7 PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY m <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 ;�� t X Cable Tool Dia. of Well Excavation /(,a <br /> Domestic/private ' a i Drilled Dia. of Well Casing16 , <br /> i Domestic/public a Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> r Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical k Surface Seal Installed„BX: <br /> ..___,...,.,.,..,.. .. <br /> I ' <br /> PUMP INSTALLATION: Contractor <br /> Type .of Pump H.P. <br /> PUMP REPLACEMENT: /M./ State_Work Done <br /> IF <br /> '. "PUMP 'REPAIR: /_7 State Work Done - <br /> ,SES RUC_TION_ 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 forma pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> After comple on of my wark on ne well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLE S REPORT PDOR w 1 an n tify them before putting.the..well in.use.. The above <br /> informatio is true t th b f knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO OUT NG A ION <br /> SIGNED TITLE <br /> M �M (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED B DATE !G <br /> ADDITIONAL COMMENTS: : <br /> PHASE II GROUT-INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY 1,DATE INSPECTION. BY t DATE %� <br /> E H 1426 Rev. 1-74,1' 1-74 2M <br />