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� I <br /> ., �tl►+� � �° SAN JOAQUIN LOCAL HEALTH DISTRICT - <br /> FO OF ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. � <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERM Permit No. ,70, <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is herby 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 /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. � <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owneres Name lgQ_ Q Y-r - -- Phone <br /> 011 <br /> Address 0 �Qs�,� City <br /> Contractor's Name License #( Phone ! ,0--7 '7, <br /> TYPE OF WORK (Check): NEW WELL '/-/ DEEPEN -/_/ RECONDITION /_7 DESTRUCTION /_7 <br /> { <br /> .i PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other /_7 f <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> II SEWAGE DISPOSAL FIELD 'CESSPOOL/SEEPAGE PIT OTHER �J% <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> � 7 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFYCATIONS w <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 I� Gravel Pack Depth of Grout Seal ' <br /> Cathodic Protection Rotary Type of Grout' <br /> Disposal 0 Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump A.P. p ? <br /> :v <br /> PUMP REPLACEMENT: j_/ State Work Done <br /> I <br /> PUMP .REPAIR: II /�(� State Work Done d —,--d <br /> ,RE5 TRUCTION_OF WELD: Well Diameter Approximate Depth <br /> �I Describe Material and Procedure <br /> I hereby agree to ecmply 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 kn4wled a6d- b ief, I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR UTING AIJD A FINAL 1 E <br /> SIGNE TLE <br /> 0 (DRA PILOT PLAN ON RIV,19RSE SIDE <br /> r !� kSdR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 1C,Z <br /> ADDITIONAL COMMENTS: <br /> PHASE 11 GROUT INSPECTION PHASE III NAL INSPECTION <br /> INSPECTION BY II DATE INSPECTION 8Y ATE <br /> µ <br /> `� E H 1426 Rev. I,1-7 4 ,_, <br />