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> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: ee 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 r <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � f <br /> .F <br /> . 1 <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/LOCATION S / d !1/ CENSUS TRACT <br /> oe <br /> Owner's Name - (� ��Y1 [ � �� ^� Phone <br /> Addresses City `s - <br /> Contractor's Name - - License #/!&XPhone <br /> a <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / , RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR 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 WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation ' <br /> }e-- 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: Contractor <br /> Type of Pump _ H.P. / <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: State Work Done [ 7_/ st../GdDd d � fay a <br /> DESTRUCTION OF WELL: Well Diameter 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 knowled e and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROTING AND A FINAL SP 0 <br /> SIGNED TITLE <br /> 0T PLAN ON JMVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY / <br /> PHASE I -7 <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS <br /> PHASE II ROUT INSPE TION PHASE III FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY ICA DATE 12- <br /> /1-�6��j,J�ea►fv d�i./�,fPA, �o�nr .�v ��70/09 <br /> 6�pub6.«,E inv� cr cr, olsU�9? <br /> E H 1426 , Rev. . 1-74 �a r 6r�,y.:�.y u� 74��D :S'. ��e 'd <br />