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5 <br /> / SAN JOAQUIN LOCAL HEALTH.DISTRICT <br /> FlB FFICE USE: ✓ 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: , (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 0S-_Z1_2 W <br /> f <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) `+ <br /> Application is hereby made tolthe San Joaquin Local Health Distinct 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 /> j <br /> JOB ADDRESS/LOCATION .Zj W d" ��r u� /Z:c, �fQ �P�, ('�f CENSUS TRACT <br /> Owner's Name I&ell,(" &4ra 4 _ Phone rZ <br /> Address =- � L/11 <br /> aS-6� 44J 4—V r; /��ll� ��C_ �iu ( City /`l 11 n1 <br /> Contractor's Name �. License #o2�-iPhone <br /> ve <br /> TYPE OF WORK (Check): NEW WELL /7DEEPEN 17 RECONDITION /? DESTRUCTION /_7 <br /> PUMP INSTALLATION /_/ PUMP REPAIR /� PUMP REPLACEMENT f7 <br /> 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 WELT. ' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 0 <br /> Industrial A Cable Tool Dia. of We11 Excavation <br /> _ Domestic/private (` Drilled Dia. of Well Casing y� 1 <br /> _- Domestic/public .1 Driven Gauge of Casing <br /> "Irrigation 71 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 /> PUM.REPAIR: . /7 State Work Done <br /> . ES•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" 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 TO G OUTING AND A FINAL I SPECTION. <br /> SIGNED - TITLE <br /> PLO PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> r <br /> APPLICATION ACCEPTED BY DATE <br /> PHASE I <br /> ADDITIONAL. COMMENTS: <jt <br /> PHAS &GROUT INSPECTION PHA I FINAL INSPECTION <br /> INSPECTION BY HATE - INSPECTION BY DATE - =� <br /> � t i <br /> ' h <br /> E H 1426 - Rev. I-74 1-74 2M <br />