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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : €0 (209) 466-6781 <br /> APPLICATION FOR �WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin„ Local Health District fora 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 /> 1 <br /> JOB ADDRESS/LOCATION - <br /> CENSUS TRACT ” <br /> Owner's Names ��'e �y-7y�v Phoned <br /> Address ��� .. .._, �.. s: .` � fa� City ' <br /> Contractor's Name 'I)m oei s;q 4- .©d.."tC 1 �. nA/6ti s„ �Llcense;a���q� 'hone._ ti <br /> I s,. <br /> TYPE OF WORK (Check) : NEW WELL/ ./, DEEPEN,/. / RECONDITION /Y/ DESTRUCTION /_7 <br /> PUMP INSTALLATION `/ PUMP REPAIR / / PUMP REPLACEMENT /-7/ <br /> Other. / / <br /> DISTANCE TO NEAREST: SEPTIC` TANK SEWER LINES /OP PIT PRIVY i �^ <br /> SEWAGE,DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINEIS PRIVATE DOMESTIC WELL ., aj PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS. <br /> Industrial Cable Tool Dia, of Well Excavations` ' <br /> Domestic/private Drilled Dia, of Well Casing _ : Ln <br /> Domestic/public Driven Gauge of Casing - <br /> Irrigation r Gravel Pack Depth of Grout Seal ' <br /> Cathodic Protection Rotary Type of Grout <br /> 'N Disposal 1 Other Other Information <br /> Geophysical Surface Seal Installed B :e <br /> PUMP INSTALLATION: Contractor .„r.ke ge r.-V42Ve%,a ..; �"���(,� �,v e <br /> Type of Pump H.P. r <br /> PUMP REPLACEMENT: / / State Work Done �F <br /> r <br /> PUMP .REPAIR: / / State Work.,,--Done, <br /> DESTRUCTION-OF WELL: Well Diameter s 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 /> i4WELL 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 INSPECT ON <br /> PRIOR TO GROUTIN D A FINAL INSPECTION. <br /> SIGNED < TITLE <br /> .(DRAW PLOT PLAN ON REVERSE SIDE) <br /> LFOR DEPARTMENT USE ONLY { <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE_ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION ! <br /> ,,INSPECTION BY DATE INSPECTION BY DATE <br /> _ <br /> E H 1426 Rev. - I-74 �'' 2M <br />