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.� I'A" <br /> SAN 30AQUTN LOCAL HEALTH DISTRICT <br /> FOR,OFFI(IR USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6731 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued .� r <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 /> r7t-4 a O A��f._q <br /> JOB ADDRESS/LOCATION �,��. �..{� 9� CENSUS TRACT <br /> Owner's Name - �S o r^, Phone <br /> Address 4 1 city , v ca <br /> Contractor's Name License # .�Phone L .121 <br /> TYPE OF WORK (Check): NEW WELL L7 DEEPEN -/ RECONDITION /7 DESTRUCTION /_7 <br /> PUMP INSTALLATION/ / PUMP REPAIR . PUMP REPLACEMENT j T <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PTT PRIVY a <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 yDia. '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 'B : <br /> 3 <br /> PUMP INSTALLATION: <br /> .Contractor �i <br /> Type .of Pump _. H.P• <br /> PUMP REPLACEMENT: <br /> /7 State Work Done ,- <br /> PUMP ,.REPAIR. { <br /> -State Work Done <br /> DESTRUCTION OF WELL: Well. Diameter Approximate Depth <br /> Describe Material and Procedure f <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, 1 --will furnish the San Joaquid 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 o �..knowledge-a d belief. I W.ILL.-CALL:FOR:A GROUTINSPECTION <br /> PRIOR TO RO TING 'AND-A FINAL TNS N; " `' <br /> SIGNED "• TILE <br /> ` D W PLOT PLAN ON RE ASE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE Z <br /> APPLICATION ACCEPTED BY DATE , <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IIIAL INSPECTION k <br /> INSPECTION BY DATE INSPECTION BY DATE -� <br /> E e1426 Rev. 1-74 _.-1sI75 2M <br />