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SAN JOAQUIN LOCM, HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 / <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.� <br /> ' /sTHIS PERMIT-EXPIRES 1 YEAR FROM DATE ISSUED Date issued <br /> (Complete In Triplicate) <br /> I Application is Aereby 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 !/I ee L pI f CENSUS TRACT <br /> Owner's Name r-A Phone <br /> Address ��"' �[' City ' <br /> Lo 4 r <br /> , Contractor's Name License # ✓phone e-33%3 <br /> I <br /> TYPE OF WORK (Check) : NEW WELL '/k?"*"DEEP EN / / RECONDITION /-7 DESTRUCTION /- <br /> PUMP INSTALLATION PUMP 'REPAIR / "% 4PUMP REPI.AC MEiVT. ./ <br /> Other l/ /- .. — <br /> DISTANCE TO NEAREST`: SEPTIC 'TANK—mm SEWER- LINES PIT PRIVY ~ <br /> ---4SEWAGE.'DISPOSAL FIELD <br /> CESSPOOL/SEEPAGE PIT OTHER <br /> I PROPERTY LINE - PRIVATE'`DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial <br /> ''I L-,.-'Cable Tool Dia. A' 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 <br /> Surface" Seal Installed By: <br /> PUMP INSTALLATION: <br /> Contractor <br /> Type of Pump rf H.P. . <br /> i <br /> jPUMP REPLACEMENT: State Work Done, i <br /> PUMP -.REPAIR: / / State Work Done <br /> k <br /> iDESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> i 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 puttingthe..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 ROUTING AND A FINALAINSPECTION. <br /> SIGNED ! TITLE <br /> i (DRAW PLOT PLAN ON REVERSE SIDE) <br /> Fa DEPARTMENT USE ONLY <br /> PHASE I 1 r <br /> ) t� <br /> APPLICATION ACCEPTED BY (T"/] DATE// / <br /> ADDITIONAL COMMENTS: , <br /> PHASE II GROUT INSPECTION 9 PHASE III/FINAL INSPECT ON <br /> INSPECTION BY DATE INSPECTION BY DATE Z <br /> E H 1426 Rev. 1-74 2M i <br />