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SAN JOAQUIN LOCAL -HEALTH DISTRICT <br /> FOR eOFFICW�— 1601 E. Hazelton Ave-, Stockton, Calif. <br /> Telephone: (209) 466=6781LICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit NoS`j� <br /> THIS FERMI_ EXPIRES 1.YEADt 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 here# described. This application is made in compliance with !San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of' Che• San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION � .3 I`i �i 2 � "r 'LCENSUS TRACT <br /> Owner's Name } �/, [fi Phone ,k— <br /> Address °1 City <br /> JSi ' <br /> Contractor's Name d LicensePhone d <br /> I; TYPE OF WORK (Check): NEW WELL -/=7 DEEPEN /? RECONDITION /7 DESTRUCTION /_7 <br /> i PUMP!INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES". PIT PRIVY 7 C� <br /> SEWAGE DISPOSAL,FIELD CESSPOOL/SEEPAGE PIT OTHER U� <br /> PROPERTY LINi- == PRIVATE DOMESTIC WELL' PUBLIC}DOMESTIC WELL R� <br /> i INTENDED_ USE STYPE--.OF WELL r. CONSTRUCTION `SPECIFICATIONS <br /> Industrial �F' �. Xable Tool Dia. of Well Excavation <br /> Domes tic/privateY , i 0, -1,=Drilled` Dia. rof-,Well Casing <br /> Domestic/public Driven Gaugeof', Casing , <br /> Irrigation t Gravel Pack Depth of Grout Seal <br /> Cathodic Protech on -tRr yp o o <br /> Disposal j �,-� N-\.Other Other Information. <br /> Geophysical Surface Seal Installed By* <br /> i PUMP INSTALLATION: Contractor <br /> Type of Pump S.P. <br /> PUMP REPLACEMENT: / State Work Done <br /> - - <br /> -PUMP''REPAIR3 - /- State Work—Done <br /> .D)ES4RUCTION 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 thetbest-of. my knowledge and belief. I WILL CAjjL FO A GROUT INSPECTION <br /> C PRIOR TO GROUTING ANDA NSPECTION. <br /> SIGNED TITLE <br /> j (DRAW PLOT PLAN ON REVERSE SIDE <br /> I FOR DEPARTMENT USE ONLY <br /> { PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: I <br /> PHASE II GROUT INSPECTION PHASE ISI/ SINAL INSPECTION <br /> INSPECTION BY <br /> DATE INSPECTION BY ,(Q _DATE -2 <br /> f _ _-- <br /> 't <br /> -74 2M <br /> E H 1426 Rev. 1'-14 1 - <br />