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� --- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOSrOFFILEICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.T�1d <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSURD ,. Date IssuZ <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 /> ,� <br /> JOB ADDRESS/LOCATION f `► CENSUS TRACT <br /> Owner's Name ���'"!�a- Phone <br /> Address <br /> Ci..... <br /> ty:. .i <br /> i <br /> Contractor's Name License #,� Phone 1 <br /> TYPE OF WORK (Check): NEW WELL 4tZ DEEPEN /7 RECONDITION_ /7 DESTRUCTION fZT <br /> PUMP INSTALLATIONk7PUMP REPAIR /% PIMP REPLACEMENT_. /7. <br /> Other / 1 -- <br /> r <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PITBOTHER A <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL ' PUBLIC TIC WELL <br /> INTENDED USE TYPE OF WELL GONSTRUCTION' SPECIFICATIONS <br /> Industrial Cable-Tool Dia. of Well-Excavation �V <br /> Domestic <br /> G� /private Drilled Dia. of Well- Casing t <br /> Domestic/public Driven Gauge of Casing c J <br /> Irrigation Gravel' Pack Depth of Gr©ut Seat <br /> Cathodic Protection Rotary Type of _Grout <br /> Disposal Other l <br /> I <br /> l Other Information <br /> Geophysical <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor "e CLe— <br /> Type of Pump t o , H.P. <br /> 2� <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP .REPAIR: /_7 State Work Done <br /> i <br /> ES;TRUCTION OF WELL: Well Diameter 1 i Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all Paws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining toorr_.regulat.ing,well construction. Within FIFTEEN DAYS f <br /> after completion of my work on a net? well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT..of2 the well and notify them before putting. the..well in use. The above <br /> information is tato the best of <br /> PRIOR TOry.k owledge and belief. I WILL 'CALL FORA GROUT INSPECTION <br /> S IN E N. <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SIDE) ` <br />—_ r ' <br /> FOR DEPARTMENT USE ONLY. <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE �� <br /> ADDITIONAL COMMENTS: 0 <br /> PHASE GROUT INSPECTION T <br /> INSPECTION BY 3 PHASE FIN INSPBCTION f <br /> DATE J l:2/-7fO 'INSPECTION BY D "'. <br /> E H 1426 Rev. 1-74 _ _[ ' <br />