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' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ik FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> ', Telephone : (209) 466-6781 �7p <br /> J APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. /d J� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ���7C� <br /> (Complete In Triplicate) <br /> C 'Application is hereby made' ta 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 Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION , A Al ENSUS TRACT <br /> Owner's Name Phone <br /> t <br /> Address City _-- <br /> Contractor's Name r License Lff y 'hone L l <br /> TYPE OF WORK (Check) : NEW WELL /C7—DEEPEN / / RECONDITION / / DESTRUCTION /-7 _ <br /> PUMP INSTALLATION /�l'UMP 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 o <br /> - INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS - a <br /> Industrial Cable Tool Dia, of Well Excavation _ �l <br /> _1,,,__ ISome s tic/private Drilled Dia, of Well Casing S <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Mary Type of Grout q <br /> Disposal Other Other Informatioii ` <br /> Geophysical = '`Surface Seal Installed By <br /> PUMP INSTALLATION: Contractor <br /> ( Type of Pump H.P. <br /> 4' - <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> ! DES-TRUCTION -OF WELL: Well Diameter Approximate Depth <br /> De-s'cribe Material an.d;,Proce•dure------ �� � <br /> 14W ' <br /> I hereby agree tc comply -with- all laws and regulation�o-f the San Joaquin-Local Health District <br /> and the State of California pertainin•g. to or regulating well'const`ructon. Within FIFTEEN DAYS <br /> after completion` of my work on a new well;, I will furnish_ the San Joaquin Local Health District <br /> WELL DRILLERS REPORT of the well and notify'themXefore putting the�well in use.. The above <br /> information is true to tfie�best of my''knowledge and b} lieff- I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU NG D A FINAL INSPECTIO <br /> r <br /> -SIGNED ° �'. -. TITLE ° <br /> (VAW PLOT,PLAN.<ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY - - "A""�—` DATE L' 11`12 <br /> y ADDITIONAL COMMENTS: <br /> PHASE II f4OUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 0/77 _ 2M <br /> E H 1426 Rev. - I-74 <br />