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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFF;;ICE' USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone (209) 466-6781 ' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> t <br /> THISPERMITEXPIRES 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 Emade in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the 'I San Joaquin Local Health District. <br /> ��f h I. <br /> JOB ADDRESS/LOCATION ���`� <br /> � 'lye-- - CENSUS TRACT � <br /> E E <br /> Owner's Name Phone y i <br /> Address e5l� Z'/ 7 M City <br /> Contractor's Name <br /> License <br /> hone <br /> -� y <br /> TYPE OF WORK (Check) : NEW WELL '/—/ DEEPEN, / / RECONDITION /_7/ DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR LI-1 PUMP REPLACEMENT Q <br /> Other / / fl <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES : PITIPRIVY 00 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL iCONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of WelI Excavation <br /> Domestic/private Drilled Dia. .-of Well1j:Casing <br /> Domestic/public Driven Gauge of. Casing <br /> Irrigation Gravel Pack Depth-of- Grout Seal <br /> Cathodic Protection Rotary_-. --s, . ,,,,„, _„ Type.-of- Grout;:.. ._ <br /> Disposal + Other Other- Information -; <br /> Geophysical ' Surface SeaflInstalled By: <br />'UMP INSTALLATION: Contractor <br /> Type of Pump IM H.P. �► <br />'UMP REPLACEMENT: State Work Done <br />'UMP '.REPAIR: / / State Work Done <br /> EES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describeimaterial and Procedure j <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> Lnd 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 /> FELL DRILLERS REPORT of the well and notify them before puttingf�the..well in use.. The above <br /> nformation is true to the best' of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> RIOR TO GRO TING AND A FINAL INSPECTION. E <br />'IGNED TITLE <br /> (DRAW PLOT PLAN ON. REVERSE SIDE) j <br /> FOR DEPARTMENT USE ONLY <br />'HASE I { �I <br /> PPLICATION ACCEPTED BYp DATE 0 - -7 7 <br /> DDITIONAL COMMENTS: <br /> PHASE 11 GROUT INSPECTION PHASE TTI/FINAL INSPECTION <br /> NSPF;CTION BY DATE INSPECTION BY Ij DATE ?7 72 <br /> E H 1426 Rev. 1-74 1/7.7 2M <br />