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9L) SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOhrOFFICE USE: 1601-E. Hazelton Ave. , Stockton, Calif. <br /> ' Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued / . -7 <br /> (Complete In Triplicate) <br /> Application is herebyImade 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 Joaqui� <br /> County Ordinance .No X1862 and the Rules and Regulations of the San -Joaquin Local Health District. <br /> JOE ADDRESS/LOCATIONS Z3-f.4'C?- (7 <br /> a. CENSUS TRACT ' <br /> 4 <br /> Owner's Name Phone <br /> Address City , <br /> r Contractor's Nance i 1 <br /> License # ,.-�9/O Phone <br /> TYPE OF WORK (Check): NEW WELL DEEPEN/� RECONDITION / DESTRUCTION /7y <br /> PUMP IMTALLATION / / PUMP REPAIR-/? PUMP REPLACEMENT 17 <br /> NOther / / -- <br /> DISTANCE TO NEAREST; SEPTIC TANK f12i 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 :i. Cable Tool Dia. of Well Excavation J1i <br /> Domestic/private Drilled Dia. of Well Casing N <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack, Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal _..' <br /> P Other Other Information " <br /> Geophysical !r Surface Seal Installed B s <br /> PUMP INSTALLATION: lContractor <br /> .,.Type .of Pump A.P. <br /> PUMP REPLACEMENT: ���/ State. Work_ Done <br /> PUMP .REPAIR: / / -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 'fork 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 TNS ON <br /> � PRYOR TO GR UTING AND. A"$ AL IN ECTI N. <br /> SIGNED T$TLE <br /> (D PLO PLAN ON RE SE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ��. <br /> APPLICATION• ACCEPTED BY, <br /> -,4az�e_ DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II ROUT iN E IONr <br /> PRASE II FINAL INSPECTION <br /> k INSPECTION BY DATE - INSPECTION BY -) DATES- �]7 <br /> i, <br /> E H 1426 Rev. 1-74 /7K--'W <br />