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d <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F'O _OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (204) 466-6781 <br /> - APPLICATION FOR WELL CONSTRUCTS OR PUMP PERMIT Permit No. <br /> a ®.2,0 z dza�., '-' d JAN'i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issue <br /> ! (Complete In Triplicate) <br /> Application is Aereby made tcd the San Joaquin Local Health District for a permit to construct' : <br /> and/or install the work hereindescribed. This application is made in compliance with San Joaquin . <br /> County Ordinance No. 1862 andlthe Rules and Regulations of the San Joaquin Local Health District. <br /> On me Arfhu'r 1 Mile_ nor-+h c)'P ff w . Oos <br /> JOB ADDRESS/LOCATION' F'i'r }_ Sp- lace n p a S }- s i P n 1P r[o _ CENSUS TRACT <br /> Owner's Name Phone - <br /> Address �Q o� ' City <br /> Contractor's Name �I 1i .License # Phone ��s j <br /> TYPE OF WORK (Check): NEW ,WELL DEEPEN / / RECONDITION / / -DESTRUCTION ,/ ` <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 CQ5 <br /> Other '/ / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES !f-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 i Cable Tool Dia. of Well Excavation M � <br /> Domestic/private } Drilled Dia. of Well Casing <br /> Domestic/public i Driven Gauge of Casing _—UnD \'1/ <br /> Irrigation Y Gravel Pack Depth of Grout Seal. tip ' <br /> Cathodic Protection A Rotary Type of Grout 'I te <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> a � <br /> f PUMP INSTALLATION: ¢Contrctor, - <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done, " <br /> .o <br /> PUMP ,.REPAIR: / / State Work Done <br /> bES-TRUCTION OF WELL: ­ <br /> Well Diameter h Approximate Depth <br /> Describe Material and Procedure <br /> 11 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 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 /> I information is true to the best of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />, PRIOR TO GROUTING AND A F'INALi INSPECTIO <br /> SIGNED ' ! TITLE <br /> a <br /> / (D&W PLOT PLAN ON REVERSE SIDE) <br /> l <br /> FOR DEPARTMENT USE ONLY ' <br />+ PHASE I i <br />$ APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I:II/ INAL:INSPECTION <br /> INSPECTION BY DATE INSPECTION BY7LT0j DATE l�r7 <br /> E H 1426 Rev. 1-74 <br />