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' e,6%t I v x6' <br /> � SAN JOAQUIN LOCAL HEALTH DIST <br /> FRICT - <br /> OITOFF CE USE: 1601 E. Razel�ton 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 Set: 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 2 <br /> `� ��� CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address .A ® ` City <br /> Contractor's Named License #l"f y hone <br /> P Z - 76 � a <br /> TYPE OF WORK (Check): NEW WELL L7 DEEPEN 17 RECONDITION f7 DESTRUCTION- /7 <br /> i <br /> PUMP INSTALLATION PUMP REPAIR /_7 PUMP REPLACEMENT /7 <br /> Other /7 <br /> r <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT MUM <br /> _ . SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ­4 <br /> INTENDEPROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL 1 <br /> D USE <br /> Industriai� ECIFTYPE OF WELL CONSTRUCTION SPICATIONS <br /> Cable Tool Dia. of Well Excavation Cu <br /> � , Domestic/private Drilled Dia. of Well Casing i <br /> Domestic/public =Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection _ •� _4 Rotary Type of Grout ; <br /> Disposal "-` <br /> Other Other information <br /> .Geophysical � Surface Seal installed B <br /> -PUMP INSTALLATION: <br /> Contractor <br /> Type of Pump <br /> A.P. dP <br /> P 11 <br /> State Work Done <br /> PUMP :REPAIR: 7 State Work Done ` <br /> ES•TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to c <br /> omply 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. <br /> information is true to the best of mywled aelief. I WILL CALL FOR A GR. The above <br /> OUT INSPECTION <br /> PRIOR TOG UTING AND A FINAL INSPECTI <br />,SIGNED r <br /> ITLE1110110 <br /> D W LOT PLAN ON FRSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY r�_ F <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY PHASE ITI- INAL INSPECTION <br /> DATE _ INSPECTION BY DATE -� <br /> E H 1426 Rev. 1-74 <br />