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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> bgc� <br /> FOI OFFICE USE; - 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _f <br /> THIS PERMIT EXPIRES ]. YEAR FROM DATE ISSUED Date lss:.=pcl <br /> (Complete In Triplicate) <br /> Application hereby made to the, San Joaquin Local Health District for a permit to construct <br /> and/or inst 11 the work herein described. This application is made in compliance with San Joaquin <br /> County Ord nance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> B ADDRESS LOCATION ) ? <br /> CENSUS TRACT <br /> errs ame <br /> Address Phone - <br /> _ -- City <br /> Contractor's Name <br /> —..._-_ ✓ License bVf Phone <br /> TYPE OF WORK (Check) : NEW WELL DELIP 'N /_/ RECOI1I)ITION 1­7 DESTRUCT10N�f/� �-- <br /> PUMP INSTALLATION / PUMP REPAIR / v/ PUY P REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK ) 1� SEWER LINES �,�-PIT PRIV <br /> SEWAGE DISPOSAL FTELD -f {;rS�p00TlSIEPAGE PIT � l .HER <br /> PROPERTY LINEA ''I�RIS7ATF. DOI'fESTIC iti�EI.,L _.'"� PLIBLTC I10M1:5TZC WELL jdk!7Y <br /> INTENDED LiSE TYPE OI' WELL _-_-.. _--_�__� E,ONST'RUC;TION SPECIFICATIONS .._�. <br /> Industrial f: Wellb fool Dza. WellExcavation <br /> Domestic/private <br /> Drilled Dia.. of Well Casing <br /> Domestic/public Driven Gauge of Casing _ � �• —__� <br /> Irrigation Gravel Pack Depth of Gr,_;ut Seal _ <br /> Cathodic Protection Rotary . <br /> Type of Grour_ ' <br /> Disposal _ Other Other Information <br /> Geophysical - !� <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Pumof <br /> Type <br /> y I p �---�-7..•� - <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work: Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure _--- --- Approximate Depth � - <br /> I hereby agree to comply with all_�.aws and regulations of-tEie San Joaquin Local Health Distz i y <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 knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTIN. - �-- --- _-- <br /> SIGNED -___. <br /> 7(DORAIi PLD' REVERSE SIDE <br /> PHASE I - FOR DEP MENT €TSE ONLYAPPLZCATION ACCEPTED BY : <br /> ADDITIONAL COMMENTS: _ --- __ _ DATE <br /> GROUT INSPECTION P /FINAL INSPECTION <br /> INSPECTION $Y DATE 1 - INSPECTION BY <br /> Xtc <br /> DATE - <br /> E H 1426 Rev. • 1-74 0/%7 21Ud <br />