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__, f SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR: OFFICE USE: 1.601. E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466--6781 <br /> APPLICATION FOR .WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> _ i <br /> THIS PERMIT EXPIRES I- 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 Joaquir <br /> County Ordinance No.. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION � /� rJ ' ✓� CENSUS TRACT <br /> Owner's Name �✓ ��.,� �Qs�z. 4 Phone <br /> Address City <br /> k <br /> Contractor's Name License # fi321hone <br /> i <br /> y _ <br /> . TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION / / DESTRUCTION /-T <br /> PUMP INSTLATION PUMP REPAIR PUMP REPLACEMENT -7 <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 G� <br /> Type /of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: /)c/ State Work Done �� le-0016 lam'. <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> IFhereby 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 k ewledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPEC U <br /> SIGNED D.01TITLE -- <br /> e (D W OT PLAN ON RVMRSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �f 7 <br /> APPLICATION ACCEPTED BY DATE G <br /> ADDITIONAL COMMENTS: <br /> ` PHASE II GROUT INSPECTION PHASE II/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ATE <br /> 2M <br /> .-E H -1426 Rev. - I-74. <br />