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I V SAN JOAQUIN LOCAL i1EALTH DISTRICT <br /> FOF�7OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. "Z!g.Sa71r� <br /> 7,-r,-6 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 /> JOB ABORM/LOCATION CENSUS TRACT <br /> Owner's Name i_ Phone <br /> Address i r�y City <br /> Contractor's Name i License Phone / <' <br /> TYPE OF WORK (Check): NEW WELLDEEPEN '/7 RECONDITION /7 DESTRUCTION /_7 {f <br /> PUMP INST LATION X PUMP REPAIR ./� PUMP REPLACEMENT 17 if <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK EWER LINES , -PIT PRIVY <br /> SEWAGE DISP SAL FIELD CESSPOOL/SEEPAGE PIHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELT,: "``PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial X Cable Tool Dia.'iof W€Ir-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"InfOthiation • <br /> Geophysical Surface Seal Installed By: <br /> i <br /> PUMP INSTALLATION: <br /> Contractor •„��. <br /> Type of Pump _ H.P. <br /> PUMP REPLACEMENT: .. / / State Work Done f <br /> PUMP.RREPAIR: %/ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth -14 <br /> Describe Material and Procedure <br /> r <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 completiors of my wor r`&ti 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 K TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TLE <br /> ( PLOT ON REVERSE SIDE4j�'/ <br /> FO'bEPA&TMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY S� DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE ETON PHASE I INAL INSPECTION <br /> INSPECTION BY ATE ' - INSPECTION BY w DATE <br /> E H 1426 Rev. 1-74 r' /7 2M\ <br />