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' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> _Ev <br /> - Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> fa;F, <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued::,/,9,&._2,_, <br /> (Complete In Triplicate) <br /> WApplication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or instar, the work herein described. This application is made In comp <br /> with Oan Joaquin <br /> : County Ordinance No. 1862 and the Rules and Regulations of the San JoaquinLocaleHealth. District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name rr QQ <br /> r �D Phone ' <br /> Address �Cj4 <br /> City <br /> r <br /> contractor's' Name <br /> cense -Phone <br /> TYPE OF WORK (Check) : NEW WELL -/? DEEPEN '/-7 RECONDITION _ <br /> I T DESTRUCTION /7 <br /> PUMP INSTALLATION -/yfr PUMP REPAIR� -7 Pump REPLACEMENT /? <br /> Other / / -- <br /> DISTANCE TO NEAREST: SEPTTC`TANK <br /> SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED SE <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELLr � <br /> UTYPE OF WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> 0 Cable Tool Dia. of Well Excavation <br /> =✓Domestic/private i Drilled <br /> Domestic/public ;i Driven Dia. of Well .Casing 1 <br /> Irrigation Gauge of Casing <br /> Gravel Pack- Depth of Grout Seal <br /> Cathodic Protection -i Rotary Type of Grout <br /> Disposal *j Other .. Other Information <br /> __Geophysical <br /> !1 . Surface Seal Installed 'B <br /> PUMP INSTALLATION: Contra; tor <br /> Type of Pump <br /> A.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: fi <br /> State Work Done I <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procure Approximate Depth <br /> ed ; <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health Di°stri ct <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my word onla new well, I will furnish the San Joaquin Local Health District a J' <br /> WELL DRILLERS REPORT of the well and notify them before putting.the..well. in use.... The above <br /> information is true to-the•besi of. my. knowledge and belief. I WILL <br /> PRIOR TO GR TING ANDA F AL INSPECTION. CALL FOR A GROUT INSPECTION <br /> SIGNED � � <br /> TITLE a <br /> t. (DRAW PLOT PLAN ON REVERSE SID <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION' ACCEPTED BY 4 <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE II GRQUT' INSPECTION PHASE III AL INSPECTION <br />[NSPECTION BY DATE INSPECTION BY i <br /> DATE 7-�7G� <br /> E H 1426 Rev. 1-74 <br />