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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> FOE ; <br /> Telephone: . (209) 466-6781 <br /> mit No. L� P <br /> APPLICATION FOR WELL CONSTRUCTION,,OR PUMP PERMIT Per <br /> THIS PERMIT EXPIRES- 1 YEAR FROM DATE ISSUED Date Issuedr3 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District far 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 nd Regulations the San Joaquin Local Health District. <br /> ' <br /> JOB ADDRESS/LOCATION SUS TRACT <br /> , <br /> Owners Name, <br /> r1__754Address City ' <br /> `` �z % �� 3'Phone <br /> { Contractor's Name _ � License 4 <br /> [' --v-- •--:::.:_-�-^°sem-=-- .ti.=.�,^-,. ::�:.- ,�._ �.....r'�_-�-�''��"-tr-'ti"�=—��•--y----..'��-_. - � .�.r�,��.�----,- ,-.�.-. .-;�_. _�-.;�;. .: .--:-'.- <br /> TYPE OF WORK (Check) : NEW WELL/� DEEPEN / RECONDITION /? DESTRUCTION.. / <br /> PUMP INSTALLATION/ / PUMP REPAIR/r(' PUMP REPLACEMENT %7 <br /> Other 1 / <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 V' <br /> y-,-INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS r <br /> Industrial Cable Tool Dia. of Well Excavation _ <br /> Drilled Dia. of Well Casing <br /> Domestic/private <br /> D6mestic/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 „h.. <br /> 4 <br /> Geophysical Surface Seal Installed By: <br /> PUMP-'INSTALLATION: Contractor <br /> Type of Pump H.F. <br /> PUMP REPLACEMENT.- / / State Work Done <br /> PUt `.REPAIR3" �S`tate Work <br /> DESTRUCTION OF WELL: Well Diameter <br /> 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-knowledge and belief. I WILL CALL.;FOR A GROUT INSPECTION, <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> D W PLAN 'ON SSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE l <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COM MLNTS: <br /> PHASE II SECTION PHASE III FINAL INSPECTION' <br /> INSPECTION BY <br /> DATE INSPECTION BY DATE j 2 <br /> E H 1426 Rev. 1,74 <br />