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'J <br /> _ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6181 <br /> APPLICATION FOR.WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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/LOCATION9 _ CENSUS TRACT <br /> Owner's. Name Phone 1-731-3 <br /> Address o City r <br /> Contractor's Name License #/�2373 Phone <br /> TYPE OF WORK (Check): NEW WELL %DEEPEN / / RECONDITION /? DESTRUCTION f_7 <br /> �., PUMP INSTALLATION ) PUMP REPAIR f / PUMP REPLACEMENT / 7 <br /> 0ther C7 <br /> DISTANCE TO NEAREST: SEPTIC`TANK_' SEWER LINES loo PIT PRIVY <br /> SEWAGE DISPOSAL FCESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL ' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL ' CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable T Pl Dia. of Well Excavation) /D <br /> Domestic/private Drilled Dia, of Well Casing € °' ( � . <br /> Domestic/public Driven ��! Gauge of Casing <br /> P <br /> Irrigation Gravel Pack Depth of Grout Seali S0 1: <br /> Cathodic Protection _ Rotary ', Type of Grout <br /> Disposals -!� ' Other Other Information <br /> Geophysical e �=_ --- Surface 'Seal Installed t <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ��___ ' r` H.P. <br /> r <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done ; , <br /> �/ <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth {` <br /> Describe Material and Procedure <br /> 4 <br /> I hereby agree to comply with all laws and regulations of the San Joa�quin ocal Health Distric�t' <br /> and_the_State of California pertaining tb'or regulating well'�constr itction. Within FIFTEEN DAYS. <br /> after completion of my work on a new well, I will 1 furnisfi-�e Sari Jo�uixi- ftal•th--District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the-well if use. The' above <br /> information true to the-best of my knowledge and belief. I WILL CALL FORA GROUT INSPECTIOTi.. ' <br /> PRIOR TOG IN ANJ A MNAL INSP M IONI. <br /> SIGNED } TITLE <br /> y�J.: PLAN ONtS E SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED BY - DATE <br /> ADDITIONAL CONMV=S: V V { <br /> PRASE 11GROUT INSPECTION PHASE, I111FIN& INSPECTION <br /> INSPECTION BY DATE INSPECTION CYWA4 DATE t <br /> 3/76 24- <br /> E 1426 Rev. 1~7 <br />