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r s ' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOA�rOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6761 +' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued Wig' <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 ��� D <br /> CENSUS TRACT <br /> Owner's Name % 5 cio <br /> 41.1one G� 6 <br /> Address ® � �� City <br /> Contractor's Name S <br /> License <br /> TYPE OF WORK (Check): NEW WELL "/7__DEEPEN ./7 RECONDITION /7 DESTRUCTION /_7 <br /> 3, .. PUMP INSTALLATION /�7 PUMP REPAIR /_7 PUMP REPLACEMENT <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 WELT. ' PUBLIC DOMESTIC WELL � <br /> INTENDED USE TYPE OF WELL <br /> Industrial CONSTRUCTION 'SPECIFICAT S <br /> Cable Tool Dia. of Well Excavation <br /> ✓Domestic/private Drilled Dia. of Well Casing,, . } <br /> Domestic/public } Driven Gauge of± Casing # <br /> Irrigation Grave] Pack Depth of Graut ;Seal f <br /> , Cathodic Protection Pack <br /> Type of Grout" <br /> Geophysics]. <br /> Disposal _ Other Other -Information' <br /> . —" Other -Information' <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> ZIE: -~% <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: /_/ State Work Done <br /> PUMP=:REPAIR• `- one <br /> ""`w/ - State=Work D <br /> ES;TRUCTION OF WELL: Well. Diameter <br /> Describe Material and Procedure Approximate Depth <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-beat of my knowledge and belief. I WILL CALL FOR "A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> f- (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEP TMENT USE ONLY <br /> Q <br /> APPLICATION ACCEPTED BY 11'� " DATE <br /> ADDITIONAL COMMENTS: I, : I ' _ _/ ,?-//-2 <br /> PHASE II,.GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br /> - 1-74 2M - .; � <br />