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Wt� , f <br /> r `Y 5 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS OFFICE USE. 1601 E. Hazelton Ave. ,. Stockton, Calif. 7 <br /> Telephone: (209) 466--6781 <br /> -7( <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No: � <br /> 41 <br /> THIS PERMIT EXPIRES 1 YEAR .FRO M .DATE 'ISSUED Date Issued <br /> r (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local health District four a permit to construct <br /> and/or instar 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 SDI .��/aI A �� /� CENSUS, TRACT <br /> Owner's Name � ��L Phone <br /> Address OE. Cc Rp/&Y 4 L City ' S' ' <br /> Contractor's Name 6 6 SS S LL License #,,9Phone g f� <br /> TYPE OF WORK (Check): NEW WELL f DEEPEN -/? RECONDITION -/? DESTRUCTION f j <br /> . PUMP INSTALLATION -/XPUMP REPAIR/� PUMP REPLACEMENT % T <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK Zgi SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD, CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE .. PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE { ; , TYPE OF WELL CONSTRUCTION SPECIFICATIONS. <br /> Industrial Cable Tool, Dia. of Well. Excavation J� Q <br /> _ Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven . Gauge of Casing / 2- <br /> irrigation <br /> ZIrrigation Gravel. Pkck Depth of Grout Seal <br /> f Cathodic Protection Rotary Type of Grout.:. <br /> _ <br /> Disposal - Other Other Information — <br /> Geophysical -Surf ace-Seal IniCAlled- By: _ <br /> PUMP INSTALLATION: Contractor <br /> Type -of Pump ' &,& <br /> PUMP REPLACEMENT: ' " ] /� State Work Done <br /> PUMP :REPAIR: /-7 'State Work Done' <br /> DESTRUCTION 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 a new well, I will furnish the,San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and` notify them before puttig,. the..well. in.use.... The above <br /> information is true to•the-best of .my.knowledge and belief. . TWILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. + <br /> SIGNED TITLE <br /> (DAW VLOT PLA"N VERSE:SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I . ....:. . .. . . ..e ��.. :. <br /> APPLICATION ACCEPTEW BY DATA ? <br /> ADDITION CO 11 <br /> P S IIINSPECTION PHASE III FINAL INSPECTION <br /> INSPECTI09-M DATE' INSPECTION BY DATE <br /> " <br /> }. E R 1426 Rev. 1-74 <br />