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x SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOP OF ICE,:.USE:� a 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 Isst <br /> (Complete In Triplicate) <br /> Application is hereby mad'e to the San Joaquin Local Health District for a permit to construct <br /> and/or. install the work bet ein described: This application is made in compliance with San Joaquin_; <br /> County Ordinance No. 1862 and the ,,R le andRegulatLo s of t. e San Joaquin Local Health District. <br /> } x!, �}Ir <br /> JOB ADDRE14 0 <br /> SS/LOCATi /� f <br /> V CENSUS TRACT <br /> Owner T s Name Phone <br /> Address .� City <br /> Contractor's Name - Licens924 Phorie}j,,KAe � � <br /> Ik ; <br /> TYPE OF WORK (Check) : NEW WELL AE I3_EPEN / / RECONDITION / / DESTRUCTION /7 j <br /> PUMP INSTALLATION /L-A—P= REPAIR / / PUMP REPLACEMENT /_ 1 <br /> Other % A <br /> l�� I <br /> DISTANCE TO NEAREST: SEPTIC TANK /&47 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 Z,--fable Tool Dia. of Well Excavation _ <br /> &-'Domestic/private Drilled Dia. of Well' Casing - j <br /> Domestic/public Driven Gauge of Casing <br /> irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout q <br /> Disposal Other Other Information <br /> GeophysicalSurface Seal Installed B 7 <br /> PUMP INSTALLATION: Contractor <br /> T pe,�of}.P.ump I <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State.-Work <br /> wDone" <br /> A, <br /> - � I <br /> DESTRUCTION OF WELL: Well- Diameter Approximate Depth <br /> Describe Material and Procedure,, <br />. 1 hereby agree to complyth all laws and regulations of the San .Joaquin Local Health District <br /> and the State of Califorr as pertaining to or regulating well -construction. i-thin 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 we1Z in use:. . The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GROU NG 1AD A FINAL, INSPECTION. <br /> SIGNED TITLE <br /> (DRA -PLOT PLAN ON REVERSE SIDE) I <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYDATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION E PHASE III/FINAL INSPECTION <br /> INSPECTION BY ��_iC / DATE - - • ,,_,INSPECTION.-BY ;.DATE' 7-:-?il-A I <br /> n <br /> E H 1426 Rev. • 1-74 177 _ 2M <br />