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- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: ��601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. a- rZL f-110 <br /> j THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6-;-;!6 <br /> iJ (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 /> .FOB ADDRESS/LOCATION � -� <br /> ��. /.�-.�, c.�,,«i ��� �,�.r� CENSUS TRACT <br /> Owner's Name Phone <br /> Address _ D City �4 ,� <br /> Contractor's Name � � �c{_,r, License # G Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN -/ / RECONDITION DESTRUCTION /-7 <br /> PUMP INSTALLATION / I PUMP REPAIR MPUMP REPLACEMENT /—T <br /> Other E7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELT, 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 Other Other Information ' <br /> Geophysical Surface Seal Installed By: - <br /> PUMP INSTALLATION: Contract <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP .REPAIR: <br /> lel State Work Done WW 2 /� '1, 1, <br /> DESTRUCTION OF WELL: Well Diameter � r Approximate 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 /> 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 FOR A GROUT INSPECTI <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> D W - PLAN 'ON RSE SIDE <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPT B AORGA R D DATE 2- <br /> ADDITIONAL COMbMTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY Z DATE. ` , <br /> E H 1426 Rev. 1-7476 2M <br /> - - r <br />