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_ E <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> f'ORiOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> v; 3 O : Telephone: (209) 466-6781 �, I <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /•S=7,�'� ; <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 ADDRESS/LOCATION 92 y Al, /Ee/f is Wa®,Q CENSUS TRACT <br /> , Owner's Name Phone <br /> 'Address --- G(/d4 City <br /> Contractorts Name License Phone .� <br /> f <br /> TYPE OF WORK (Check): NEW WELL /ZT—DEEPEN -/-7 RECONDITION /7 DESTRUCTION !7 <br /> PUMP INSTALLATION / / PUMP REPAIR 17 PUMP REPLACEMENT iT <br /> Other /—/ <br /> DISTANCE TO NEAREST: SEPTIC TANK�� SEWER LINES le PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL f� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS -t-` <br /> Industrial C,--Cable Tool Dia. of Well Excavation Ire <br /> r,,—Domestic/private Drilled Dia. of Well Casing s <br /> t 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 /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done , <br /> i <br /> PUMP 'REPAIR: /-7 State Work Done _ <br /> &ESTRUCTION 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 i <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a 1 <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 TO G�q <br /> ,2TIEG AND A F INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE i <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 4 DATE <br /> ADDITIONAL COMMENTS: <br /> PH <br /> Aa,e,TjI AROUT-INSPECTIQNPHA II AL NSPECTIO <br /> INSPECTION BY r ATE �" INSPECTION.BY DATE <br /> 'w .5.� - <br /> 't � E H 1426 Rev. l 74 I-74 Co <br />