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SAN JOAQUIN LOCAL HEALTH DISTRICT .m <br /> FOFi.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> .1 Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED • Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made ,tu 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 <br /> U CENSUS TRACT <br />` Owner's Name C-T0p1 �'L Q <br /> S Phone <br /> Address. <br /> city ,roxh <br /> l Contractor's Name <br /> Phones <br /> License 1 T. <br /> � � /3 � <br /> i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /% RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other 1/ / <br /> L <br /> DISTANCE TO NEAREST: SEPTIC TANK ���L SEWER LINES ��FIT PRIVY o <br /> . SEWAGE DISPOSAL FIELD . ' CESSPOOL/SEEPAGE PIT OTHER C <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial - t Cable' Tool Dfa- of. Well Excavation <br /> Domestic/private Drilled � - Dia.Jof ,Well Casing <br /> Domestic/public Driven <br /> Gauge of Casing <br /> Irrigation .�fi 'Gravel-Pack- Depth of Gfout Seal <br /> Cathodic Protection Rotary `5 <br /> Disposal Type Grout <br /> Other Other Information <br /> Geophysical 7, --r :77 ""Surf ace,Seal Installed B <br /> PUMP INSTALLATION: ` <br /> Contractor f <br /> Type of_ Pump <br /> H.P. <br /> PUMP REPLACEMENT: <br /> State Work Done OOP <br /> .PUMP REPAIR• , : <br /> / / �S•tate "aWork Done <br /> DESTRUCTION OF WELL: Well Diameter � <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply with all law's'arid regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well 'construction. Within FIFTEEN DATS <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 est of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION 1 <br /> PRIOR TO GROU NG AND A F INSPE ION, <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I I FO DEP NT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE 1S + <br /> PHA E II GROUT INSPECTION PHAS TION <br /> III/FINAL INSPEC <br /> INSPECTION BY � � DATE ' <br /> INSPECTION By _1 DATE 3--927-9g ! <br /> E H 1426 Rev. 1-74 ec�f <br /> W7 oar s <br />