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vrt /t/04? <br /> � � SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO&.O BICE USE: 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 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 /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION .`� S� ` �CGa.hfj b CENSUS TRACT <br /> Owner's Name Phone <br /> Address srli�a. c. City <br /> Contractor's Name License ��,�y,)_ Phone <br /> TYPE OF WORK (Check) : NEW WELL.'/7 DEEPEN '/? RECONDITION /? DESTRUCTION /-7 <br /> _ <br /> PUMP INSTALLATION ,/ / PUMP REPAIR '/ / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY I" <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIMATE DOMESTIC WELL ' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <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 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 /> Type of Pump �r H.P. <br /> PUMP REPLACEMENT: . ZL</ State Work Done <br /> PUMP ,REPAIR: /7 State Work Done <br /> aES•'TRUCTION 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 /> and <br /> 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 ow dg elief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL NSPE N. <br /> SIGNED <br /> KDRAW PLOT LAN ON —R—EIT&E SIDE) �� <br /> PRASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II 4ROUT INSPECTION PHASE III FINAL INSPECTIO j <br /> INSPECTION BY DATE INSPECTION BY DATE J> ! L S <br /> E H 1426 Rev. 1-74 h/75 .2N., <br />