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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> jLEE APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR 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 herein described. This application is made in compliance with San Jo,%quii <br /> f County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION a k CENSUS TRACT <br /> Owner`s Name � /1� Phone <br /> Addressdu I All Z I q3L City <br /> Contractor's NameA&C�9AI"fjLicense 1/ ! Phone <br /> ' TYPE OF WORK (Check) : NEW,WELL DEEPEN /_% RECONDITION / / DESTRUCTION /-7 <br /> `�PUMP INSTALLATION '/ / PUMP REPAIR / / PUMP REPLACEMENT /-J <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 5Q'.,-SEWER LINES PIT PRIVY --1. <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ---- <br /> PROPERTY LIdE/® PRIVATE DOMESTIC WELifA, PUBLIC DOMESTIC WELL --� <br /> INTENDED USE TYPE OF WELL � . 1.---CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia:--of Well Excavation it <br /> Domestic/private Drilled Dia: of Well-Casing <br /> ---- <br /> Domestic/public Driven Gauge of Casing � . <br /> IrrigationY Gravel Pack Depth .of Grout-Seal r <br /> Cathodic Protection Rotary_ T Type of Grout <br /> Disposal N 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 /> PUMP '.REPAIR: /% State Work''Done E <br /> � T <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth, <br /> Describe Material and Procedure ' <br /> k <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 we11 ''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 puttingthe- well in use.. The above <br /> information is true to the best o my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO .jROyINq&MD A ' T ECT ION, t . <br /> SIGNED ~' TITLE _ qq <br /> U (DRAW PLOT PLAN_ ON rIEVERSE SIDE) J <br /> FOR DEPARTMENT USE ONLY - <br /> PHASE I, <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIO PHASE III/FINAL INSPECTION <br /> INSPECTION BY e" DATE f aINSPECTION BY /J DATE <br /> E H 1426 Rev. 1-74 J. -0 1177 2M <br />