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SAN JOAQUIN LOCAL HEALTH DISTRICT i <br /> LOS-OFFICE USE: t 1601 E. Hazelton Ave. , Stockton, Calif. <br /> � Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �S`jdGrJ <br /> t <br /> THIS PERMIT EXPIRES 1- YEAR FROM DAVE ISSUED Date Issued �lr <br /> (Complete In. Triplicate) <br /> Application is hereby made to the Stn Joaquin Local Health District for a permit to construct <br /> and/or install- the work herein described. This application- is made Incompliancewith San Joaquin <br />. County Ordinance No. 1862 and the Rules and,Regulations of the San Joaquin ocal Health District. <br /> JOB ADDRESS/LOCATION ��a —` <br /> . C SUS TRACT <br /> �-- �. <br /> Owner's Name Phone ' (` <br /> Address, q 0 <br /> City e <br /> Contractor's Name <br /> License # Phone . <br /> TYPE OF WORK Check) : <br /> NEW WELL -DEEPEN 17 RECONDITION /_? DESTRUCTION I-j <br /> PUMP INSTALLATION / / PUMP REPAIR/? PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK le <br /> SEWER LINES PIT PRIVY --- <br /> SEWAGE DISPOSAL FIELD .10 CESSPOOL/SEEPAGE PIT *-- OTHER — Y <br /> PROPERTY'LINE PRIVATE.DOMESTIC WELL" PUBLIC DOMES' <br /> �— <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ' <br /> Industrial Cable Tool Dia. of Well Excavation 4 r <br /> Domestic �� / - <br /> /private Drilled Dia: of Well. Casing <br /> 'Domestic/public Driven Gauge of Casing / <br /> Irrigation t Gra <br /> el Peck Depth of Grout Seal SC. <br /> Cathodic Protection Roary Type of Grout ' d b7wmgr <br /> Ten <br /> Disposal er a Other Information ' s <br /> Geophysical Surface Seal Installed By: Ci— <br /> PUMP INSTALLATIONo <br /> Cont' ct <br /> e. of H.P. <br /> PUMP REPLACEMENT: / / Stat G Work Done <br /> PUMP :REPAIR: k <br /> State Work Done <br />)ES-TRUCTION 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 <br /> and the State of California pertaining tlth Dis <br /> o or regulating well ��construction. WithinaFIFTEEN tDAYS <br /> rict <br /> after completion of my work on anew well, I will furnish the San Joaquin Local Health District a <br /> aELL DRILLERS REPORT of the well and notify them before putting.. the..well. in.use... The above <br /> iformation is true to the-best.of my,knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> tIOR TO GROUT D A FINAL INSPECTION. <br />;IGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> MASE I FOR DEPARTMENT USE ONLY <br /> 'PLICATION ACCEPTED BY _ DATES <br /> DDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> YSCTION BY DATE INSPECTION BY DATE <br /> 1426 Rev. 1-74 <br />