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j <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0 OFFICE USE; J�7-0 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 ,2' 1-17 <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 Joaquin <br /> County Ordinance Na. 1862 <br /> gn jhz Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Az t CENSUS TRACT <br /> Owner's Name Phon 5 <br /> I <br /> Address City ' <br /> � n <br /> Contractor's Name U License#� Phone* <br /> TYPE OP (Check) NEW WELL; j� DEEPEN / WRECONDITION /_/ DESTRUCTION /� <br /> PUMP INST ATION / / PUMP REPAIR '/ / PUMP REPLACEMENT /� <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK/A a� 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 AA'� <br /> Industrial Cable Tool Dia. of Well Excavation 1 6 (u <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic <br /> /public Driven Gauge of Casing r <br /> Irrigation ;. Gravel Pack Depth of Grout Seal <br /> Cathodic Protection ! Rotary Type of Grout <br /> DisposalOther Other: Information <br /> Geophysical _ . Surface Seal Installed B <br /> PUMP INSTALLATION: <br /> Type of Pump.-�' LtLAt H.P. <br /> PUMP REPLACEMENT: <br /> / / State Work Done <br /> PUMP .REPAIR: 17 <br /> / / State Work Done <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 <br /> WELL DRILLERS REPORT of the we11 and notify them before putting-the well in use. The above <br /> information is true to the bestlof my knowledge and belief. I WILL- CALL FOR A GROUT INSPECTION <br />'RIOR TO GR UTING INA -�PECTION. <br /> SLGNED I. TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ,/7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION �y <br /> INSPECTION BY DATE INSPECTION BY g:2 DATE �// • �O <br /> E H 1426 ' Rau_ I_7[, U77. .. • 2M <br />