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SAN JOAQUIN LOCAL HEALTH DISTRICT l` `�� _ <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Califs <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 <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 /> Count4dyiance o 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB DRELOCA I , I E S T CT <br /> � � N' �Y1 CENSUS RA <br /> Owner's Name Phone <br /> Address ! ZZ City <br /> Contractor's Name AlloQ�-x- /�r�,y-»s1y�C License #Z9dZ;,V1Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL a DEEPEN/ / RECONDITION f-1 DESTRUCTION /-7 <br /> PUMP INSTALLATION J / PUMP REPAIR/ / PUMP REPLACEMENT / 7 <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 ZAQ <br /> Domestic/private Drilled Dia. of Well Casin <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 <br /> - v Type of Pump . H.P. 3 <br /> PUMP REPLACEMENT _ y <br /> State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> e� <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all lams 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 the well and notify them before putting the well in use. The above <br /> information is tr to the-best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR FTNL INS2ECTIONol <br /> SIGNED TITLE <br /> DRAW P14T PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _+ ` DATE `< <br /> ADDITIONAL COMMENTS-.\,,V r-p <br /> PHASE II G90UT-- NSPE TION _. - PHK 1F AL INSPECTION <br /> INSPECTION BY DATE INSP`L'CTTEJNBYy , DATE p 2-) 77 <br /> l.' o -t 7�,,`�', ¢ r t y; ,/�!a f a� C s wAU 461t e./ , R/0 <br /> E H 1426 Rev. 1-74 �+F �►`''-�r"f.` �!. r .t� .�k76,�. <br />