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l <br /> i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: /W 1601 E. Hazelton Ave. , Stockton, Calif. <br /> j Telephone: (209) 466-6781 i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ZZ-939P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued - 7 <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 Joequin <br /> County Ordinance No. 1862 and�the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> ", Q CENSUS TRACT � <br /> jS <br /> Owner's Name Phone /W­ <br /> Address Address <br /> City <br /> Contractor's Name Q Q License #_A ( Phone <br /> 1 <br /> r _ _ % <br /> TYPE OF WORK (Check) : NEW WELL '/ / DEEPEN / f RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION J / PUMP REPAIR PUMP REPLACEMENT /_ <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 �J <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial i Cable Tool Dia. of Well Excavation Q <br /> Domestic/private Drilled Dia. of Well Casing pR, <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: ContraItor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . {' <br /> State Work Dane <br /> PUMP .REPAIR: State Work Done Add <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe-Material and Procedure <br /> _ y <br /> I hereby agree to comply 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 Jpaquin 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 knowledge and belief. I WILL CALL FOR A "GROUT INSPECTION <br /> PRIOR TO OUTING AN_ A FIN INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I j <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BYDATE <br /> ADDITIONAL COMMENTS: <br /> PHASE I GROUT INSPECTION PHASE TTI/FINAL INSPECTION <br /> INSPECTION BY x ` DATE INSPECTION 'BY DATE L <br /> E H 1426 Rev. 1-74 ��77 - 2M <br />