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m �G�� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR:OFFICE USE: 1601_ E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: .(209) 466-6781 <br /> 1W <br /> s 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 instar 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 /iJ pct CENSUS TRACT <br /> Owner's Name f eo� Phone <br /> Address (, ~�" City <br /> Contractor's Name .LP-47,+3 alw r �� _W. License # L,71�rft one x -�d7zr <br /> TYPE OF WORK (Check): NEW WELL.'/-7 DEEPEN '/'7 RECONDITION /_7 DESTRUCTION ff <br /> PUMP INSTALLATION / / PUMP REPAIR%� PUMP REPLACEMENT /f <br /> Other /% <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 Cable Tool Dia. of Well Excavation 9v <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation 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: , j/ / State Work Done <br /> PUMP :REPAIR: /)C/ State Work Done Ile- ,il <br /> DES-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.k owledge'-and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO ROUTING AND A FINAL I <br /> SIGNEITLE <br /> (DRAW PLOT PLAN ON RVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYY DATE - -2(a <br /> ADDITIONAL COMMENTS: <br /> PHASE IAC GROUT INSPECTION PHA INSPECTION <br /> INSPECTION By DATE INSPECTION BY DATE r <br /> E H 1426 Rev. 1-74 h/7_5 22N <br /> r <br />