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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF�;OFFICE USE: 3601 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 Issue d '.-'7t <br /> (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 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 ,-a 6 9 y E <br /> CENSUS TRACT <br /> Owner's Name Y-� <br /> C4 Phone a 12, <br /> Address city , ZS(2/9/, Al <br /> R <br /> Contractor's Name A. 41036A-) License Phone g SQ <br /> TYPE- OF WORK (Check): NEW WELL 17 DEEPEN /7 RECONDITION /_7 . DESTRUCTION / I <br /> PUMP INSTALLATION/ / PUMP REPAIR ' F <br /> Other + —PUMP REPLACEMENT 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESu PIT PRIVY - <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> • PROPERTY LINE - PRIVATE DOMESTIC WELL" PUBLIC DOMESTIC WELL <br /> INTENDED USE -.r TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Diad of' Well Excavation <br /> Domestic/private DrilledE Dia. of<Well Casing Oji <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack .Depth of-Grout Seal <br /> Cathodic Pr_otection 'Rotary Type of Grout , <br /> Disposal Other ��- Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> -Type .of Pump H.P. , <br /> PUMP PLACEMENT: State Work Done ; <br /> PUMP :REPAIR: <br /> State Work Done jg1f <br /> DESTRUCTION OF WELL: Well Diameter f . <br /> ' Apprbximate`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 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 /> aELL 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 FORA GROUT INSPECTION <br />'RIOR TO GR UTING AND FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br />?HASE Ii ' # `' ` <br /> k?PLICATION ACCEPTED BY, DATE <br /> kDDITIONAL COMMENTS: r <br /> PHASE II-,GjLOUT 'INSPECTION PHASE III FINAL INSPECTION <br /> CNSPECTIONBY ' DATE INSPECTION BY DATE <br /> F <br /> 1 <br /> . 'E H 1426 Rev. 1-74 <br />