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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF1:OFFICE USE 1601 E. Hazelton Ave. , ,Stockton, Calif.} <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMT ermit No. ;-5-1 '00 � <br /> r � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ^ <br /> (Complete In Triplicate) <br /> Application is 'Aereby made tojthe 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 and1the Rules and Regulations of the San Joaquin Local Health District. 1 <br /> JOB ADDRESS/LOCATION c CENSUS TRACT ' <br /> 1 <br /> Owner's, Name ' Phone . <br /> Address ` 3Ct- City �rt' <br /> Contractor's Name �_ `� ..License 0_4 Phone <br /> E5 r' <br /> i <br /> TYPE OF WORK (Check): NEW WELL /� DEEPEN / / RECONDITION/7 DESTRUCTION f7 y <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES E 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 rCONSTRUCTION SPECIFICATIONS �.� <br /> Industrial s Cable Tool Dia. 'of WWell Excavation <br /> Domestic%private Drilled Dia. '.of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation. ;`` :-,Gravel--.Pa-ck___ of: Grout Seal > <br /> - Ca thodi1c;Ptpt,ection. ,.1 ,77Rotary-___ _______ _T.ype_.of Grout <br /> DisposalOther Other Information <br /> Geophysical Surface §eal Installed B i <br /> PUMP INSTALLATION: _Cofitr ctor ��J <br /> Type of Pump H.P. <br /> r 7 a <br /> PUMP REPLACEMENT: �S,t t Work Done <br /> PUMP .REPAIR: / / State Work Done - -- <br /> DESTRUCTION 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 the State of California pertaining to or regulating w6.11"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 knowledge and belief., I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AU t)FINAL INSPECTION. <br /> SIGNED ,- <br /> �.- =(DRAW',PLOT PLAN.ON REVERSE SIDE) <br /> I FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY i DATE f <br /> ADDITIONAL COMMENTS: J ; <br /> PHASE II G OUT INSPECTION PHAS I/FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE _5--2J'-7 7 <br /> .. <br /> . 1177. - ' 2K <br /> E H 1426 Rev. 1-74 . <br />