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�45M / SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE E: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 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 lT`�:�' <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 /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name l p �/�rl� �o f Phone <br /> i <br /> Address 4C City 1� <br /> Contractor's NameLicense / Phone � - <br /> TYPE OF WORK (Check): NEW WELL /� DEEPEN /-7 RECONDITION /-7 DESTRUCTION f <br /> PUMP INSTALLATION / / PUMP REPAIR& PUMP REPLACEMENT f <br /> Other j/7 <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 WE .L <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well. Excavation <br /> �c 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 . i <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor I <br /> Type of Pumpa H.P: <br /> PUMP REPLACEMFSNT:% . / / State Work Done �t ;w,. <br /> PIMP .REPAIR: `. / / 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 California pertaining to or regulating well'-construction. Within FI$TSEN 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 abo've' <br /> information is true to the.be £a my.know and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TOG UTIAIG AND A FINAL NSPE I '` .. <br /> SIGN �D TITLE <br /> TDRAWP= PLAN''ON' RSE SIDE {, <br /> FOR D TMENT YSE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED B r ASN v FLDATE f�I7a <br /> ��" <br /> ADDITIONAL COMMENTS: � <br /> PIi9 I GROUT INSPECTION P Fi INSPECT oT _ <br /> INSPECTION BY DATE INSPECTION DATF�1' ' <br /> f <br /> YE B 1426 Rev. 1.,74 V76 2KF <br />