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SAN JOA UIN LOCAL HEALTH DISTRICT F ~� <br /> Q � <br /> FO$,;5FFICE USE: <br /> / 1601 E. Hazelton Ave. , Stockton, Calif. ti..� �d 7� _77j" <br /> z Telephone: (209.) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7ja <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date issued &-,71 <br /> (Complete In Triplicate) <br /> Application is hereby made tolthe 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�1the Rules and Regulations of the San Joaquin Local Health District. I <br /> JOB ADDRESS/LOCATION KfCENSUS TRACT <br /> Owner's Name .� , it I h 4� Phone , <br /> Address Ctrl !_ City <br /> ` V - <br /> Contractor'si. Name f License # iy37iS-__Phone <br /> TYPE OF WORK (Check) : NEW WELL. / DEEPEN '/ _ RECONDITION /� DESTRUCTION /_7 <br /> PUMP INSTALLATION /-7/ PUMP REPAIR X7 PUMP REPLACEMENT f_7 <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 i ; Drilled Dia. of Well Casing . <br /> Domestic/public I Driven Gauge of Casing <br /> Irrigation H Gravel Pack_ Depth of Grout Seal <br /> Cathodic Protection cl Rotary Type of Grout ' �a <br /> Disposal _ j Other Other Information <br /> -Geophysical Y.� Surface Seal' Installed^'By: _ <br /> PUMP INSTALLATION: Contractor "" W O 1 <br /> Type .of Pump rG H.P. c� <br /> PUMP REPLACEMENT: . /_7 State Work Done <br /> PUMP I REPAIR: .State Work Donee,✓ �m2 y« zz <br /> y <br /> DESTRUCTION OF WELL:. Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 1 <br /> I hereby agree to comply withtall laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well'-conseructi.on. Within FIFTEEN DAYS <br /> jafter 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,luse.... The above <br /> information is true to-the-b . of my.-knoy�xled a and belief. I WILL CALL FOR 'A'GROUT INSPECTION <br /> PRIOR TO OUTING ' D A FINAL . S E 10 <br /> SIGNE -" �` .r •�a ITLE <br /> (DRAW PLOT PLAN ON EtRSE ,SIDE) <br /> fV FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED RY DATE 1 <br /> ADDITIONAL COMMENTS: <br /> PHASE -II GROUT 199PECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ;; DATE �3 <br /> E H"1426 Rev. I-Ili <br />