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SAN JOAQUIN LOCAL HEALTH DISTRICT a, <br /> FOE: OFFICE USE: ,J 1.601 E. Hazelton Ave. , Stockton, Calif. �tj�17/� <br /> 11 Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 10b <br /> THIS PERMIT;, EXPIRES 1 YEAR FROM DATE ISSUED, Date Issuedj <br /> ' (Complete -In Triplicate) 2. 03-020--0,� <br /> ' Application is hereby made to the San Joaquin Local Health District for a permit to construcfi <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> f County Ordinance No. 1862 and the Rules .:and Regulations of the San Joaquin Local Health3District <br /> T('O Lf 2S S I-V l AhEr ' 1 N <br /> JOB ADDRESS/LOCATION.. NSUS TRACT <br /> Owner's Name i , Phone <br /> 1 <br /> Address Ph/ f 4::F City <br /> Contractor's Name ` License #•s Phone 1,. <br /> { <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / X`• / __ <br /> IDISTANCE TO NEAREST: SEPTICiTANK SEWER LINES PIT PRIVY <br /> SEWAGE'AISPOSAL�`FIELD"' "' _ CES'S POOL/SEEPAGE-P'IT r OTHER <br /> 1 PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL- <br /> INTENDED <br /> ELLINTENDED USE 1 tTYPE-,OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial tis --__-' Cable Tool Dia. of Well Excavation i. <br /> Domestic/private '-Drilled Dia. of Well Casing AA id <br /> t Domestic/public t Driven x Gauge:of .Casing f <br /> Irrigation ! t Gravel PackDepth of Grout Seal <br /> Cathodic Protection: Rotary Type of Grout <br /> f Disposal Other Other Information <br /> Geophysical Surface Seal. Installed By' <br /> PUMP INSTALLATION: Contractor <br /> Ty of Pump <br /> ' PUMP REPLACEMENT: / / { State Work Done ' <br /> _; <br /> PUMP .REPAIR: / / ' State Work Done � t <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 /> sand the State of California pertaining to or regulating well 'constructi-on. Within FIFTEEN DAYS <br /> iafter completion of my work 'on a new well, I will furnish the San, Joaquin Local_ Health District a <br /> WELL DRILLERS REPORT of theywell and notify them before putting thewell in use. The above <br /> ' information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO TING AND INSPEC' 'ION. > <br /> SIGNED A, avda TITLE - <br /> j 1 (#AAW PLT PL REVERSE SIDE) <br /> f k F DE ARTMENT USE ONLY <br /> PHASE I # DATE cS� <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL ,COMMENTS: _:1- - - - V <br /> PHASE II 2ROUT IINSPECTIQN � �,' PHASE III/FINAL INSPE TI N <br /> INSPECTION BYE(/ „ 'DATE` INSPECTION' BY -- DATE <br /> Y <br /> n/77 <br /> E H 1426 Rev. . 1-74 �� <br />