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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFCE USE: jr✓ 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 /> r� (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 herein1described. This application is made in compliance with San Joaquit <br /> County Ordinance`No. ' 1862 and�the Rules and Regulations of the San Joaquin Local Health District.' <br /> r� <br /> JOB. ADDRESS/LOCATION ' 44 :�.� CENSUS TRACT t <br /> Owner's Name "` � ��'t - Phone <br /> I <br /> Address r trt ` p ,r'��r_ City 0- 1776-':--�� <br /> � , <br /> Contractor's Name �-f� �rrre rh '!'c��! License �� v < r''Phone % <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN %/ RECONDITION /—/ DESTRUCTION /,77 <br /> PUMP INSTALLATION 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 <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 I Other Other Information 4 <br /> Geophysical Surface Seal Installed By.!!/ <br /> PUMP INSTALLATION: Contr,aator �, � � 1/v�v� "� ' 4V - <br /> .. .� Type ofPump <br /> P13MP REPLACEMENT: f / /,., State Work Dbhe - ''-? <br /> PUMP -.REPAIR:., / / State Work Done <br /> DESTRUCTION OF WELL: Welt-,D.i�m�ter Approximate= Depth <br /> Desc`-rite. Material and Procedure ' <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Lo'cal; 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. The above <br /> information is true to the best of my knowledge and belief. ` I WILL CALL FORiA GROUT INSPECTION <br /> PRIOR TO GROUTING D FINAL INSPECTION. ( , <br /> SIGNED ��� (�� . _ � TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA§E I INAL NSPECTION <br /> INSPECTION BY DATEA/Zh__ <br /> INSPECTION BY DATE?2 7_ <br /> 11.27 2M <br /> E H1426 Rev. 1--74 .-.- <br />