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f_._... . � ^ / SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR WFICE USE: Y 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 <br /> f (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District foraermit to construct <br /> uct <br /> Land/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 />' JOB ADDRESS/LOCATION S' fI � CENSUS TRACT o8'7—lc �zS <br />` Owner's Name <br /> } e N Phone <br /> r Address t Gv CityaG� ! <br /> s <br /> 6 Contractor's Nave License #p / Phone <br />� f <br /> TYPE OF WORK (Check): NEW WELL DEEPEN / RECONDITION /t DESTRUCTION f <br /> PUMP INSTALLATION / / PUMP REPAIR /� PUMP REPLACEMENT <br /> Other / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGEDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER � . <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL Z <br /> INTENDED USE TYPF OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> t Domestic/private Drilled Dia. of Well Casing <� <br /> Domestic/public Driven Gauge of Casing <br /> I Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information i <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION:' <br /> Contractor <br /> c Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done ` <br />' PUMP 'REPAIR: __._. <br /> /��State Work Done <br /> D, EES RUCTION OF WELL: Well Diameter _ __ Approximate Depth <br /> Describe Material and Procedure" <br /> 1 <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 DR REPORT of the well and notify them before putting.. the..well in.use.. The above t <br /> infor ation is tru to the-best ,of my knowledge and belief. I WILL CALL FOR A -GROUT INSPECTION <br /> PRIOR GROUT N A FINAL NSPECTION. <br /> SIGNED TITLE <br /> y (DRAW PLOT PLAN ON REVERSE SIDE 1 <br /> ` FOR DEPARTMENT USE ONLY I <br /> PRASE I <br /> APPLICATION ACCEPTED BY DATE 'S 37 ' <br /> ADDITIONAL COMMENTS: M <br /> PHASE II GROUT INSPECTION PHASE UI FINAL INSPECTION <br /> INSPECTION BY DATE - INSPECTION BY DATEbt <br /> i E H 1426 Rev. 1-74 t_74 7M <br />