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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOfliO F CE USE: 1.601 E. Hazelton Ave. , .Stockton, Calif. <br /> Telephone: . (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. LELkO <br /> rna . s <br /> THIS PERMIT EXPIRES 1 YEAR' FROM DATE ISSUER Date Issued <br /> a (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 Rules4and ,Regulatkons o£���he San Joaquin Local Health District. <br /> � �, CENSUS TRACT <br /> .IOD ADDRESS/LOC 9 a <br /> .. Phone <br /> Owner's Name Cit <br /> Address LLe�`�-' / 9 • <br /> ` Contractor's N U <br /> - License�` '� Phon C'3 <br /> -7 D <br /> TYPE OF WORK (Check) : NEW WELL -/-7 DEEPEN/-T RECONDITION / EREPLACIEI+'�N��T <br /> PUMP INSTALLATION /PUMP REPAIR / ON� <br /> t Other /_7 <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 <br /> INTENDER USE TYPE OF WELL T CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation a <br /> Domestic/private Drilled Dia. of Well Casing t <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 Surface Seal Installed By: <br /> f <br /> PUMP INSTALLATION: Contractor ' <br /> Type 'of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work. Done <br /> PUMP- REPAIR:'— State-Work Dori <br /> &TRUCTION OF WELL Well Diameter 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 's new well, I will furnish the San Joaquin Local Health District <br /> WELL DRILLERS REPORT of the well and notify thew 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 /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> :FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> I PHASE II GROUT INSPECTION PHASE I INAL CTION <br /> 1 INSPECTION BY DATE 1. 4SPECTION BY X <br /> 1-74 2M <br /> i 't E H 1426 Rev. Z-74 - <br />