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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR!OFFICE 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 <br /> (Complete In Triplicate) 4>' <br /> Application is hereby made to the San Joaquin Local Heal th'..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 No. 1862 and the Rules and Regulations.of, the,,San'=.Joaq.uin Local Health•`Disti ict.. - <br /> JOB ADDRESS/LOCATION ,1 / L 7 `�7 CENSUS.-TRACT', <br /> Owner's Name f��'�r! G� [ c � s'��rsri� .. Phone <br /> Address ova City _ <br /> Contractor's Name License # hone. -d <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /? RECONDITION /_7 -DESTRUCTION <br /> PUMP 'INSTALLATION 0( PUMP REPAIR /-7—PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 3T7 1 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD _.:3L CESSPOOL/SEEPAGE-PIT OTHER <br /> PROPERTY LINES PRIVATE DOMESTIC- WELL` PUBLIC 'DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable:Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven ' Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal -fes <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 PumpH.P. ! <br /> PUMP REPLACEMENT: j_/ State Work Done <br /> PmREPAIR: /_7 State Work Done <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> ..r-4 <br /> Describe Material and Procedure <br /> I`_he=eby 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 knowledge and belief. I" WILL OUT INSPECTION <br /> PRIOR TO_.GROUTING D 'A FINMi=EPSPECTION. r <br /> SIGNEDosv TITL <br /> ' (DRAW PLOT PLAN ON REVERSE SIDE s <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL CON MTS: <br /> PHA§ 'II GROUT INSFKCTIOPHASE_111/PINAL INSPECTION <br /> INSPECTION BY DATE 7� INSPECTION BY DATE g' <br />� 1 ;E H 1426 Rev. 1-74 1-74 2M CIO ` <br />