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SAN JOAQUIN LOCAL HEALTH DISTRICT - - <br /> FOReOFFICE USE: -Z- <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. I'zl—STS <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 Joaquini <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District, <br /> F <br /> JOB ADDRESS/.LOCATION CENSUS TRACT <br /> Owner's Name <br /> Phone 7 e- <br /> Address am ie <br /> i <br /> City <br /> Contractor's Name License #62 9010 Phone <br /> TYPE OF WORK (Check): NEW WELL /? DEEPEN RECONDITION /? DESTRUCTION f7 1 <br /> ~ PUMP INSTALLATION •/ / PMP REPAIR PUMP REPLACEMENT 1 <br /> Other--/-7 -, <br /> r <br /> DISTANCE TO NEAREST: SEPTIC' 'TANK � .� `SEWER_:LINES : �/PIT PRIVY <br /> SEWAGE�,DISPOSAL FIELD F-1, CgSSPOOL/SEEPAGE PIT OTHER j <br /> PROPERTY LINE - PRIVATE DOMESTIC Witt PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL oi CONSTRUCTION SPECIFICATIONS S <br /> Industrial Cable Too"J '-'' i�,r Dia. of Well Excavation <br /> Domestic/private Drilled Dia. ��o"f Well Casing <br /> Domestic/public Driven Gauge of Casing O <br /> Irrigation Gravel Pack Depth f Grout Seal <br /> Cathodic Protection Rotary Type !f Grout <br /> Disposal Other Othei�ITnformation =- <br /> Geophysical Suxface Seal Installed By: <br /> PUMP INSTALLATION: Contractor , <br /> Type of Pump s H.P. <br /> PUMP REPLACEMENT-*.-.. -//--State-Work--Done <br /> PUMP :REPAIR:' ' "' "State Work Done <br /> ,'LEST RUCTION OF WELL: Well Diameter Approximate Depth � <br /> Describe Material and Procedure <br /> NA <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertainingtto 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 befef.1 WILL, CAL FOA A GROUT INSPECTION <br /> PRIOR TO GROU NG AN.D AKNAL INSPECTION. f <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE'ONLY <br /> PHASEI <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: waA,.1 <br /> PHASE II GROUV INS ECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY E _ DATE ID--.A o <br /> t E H 1426 . Rev. I-74 1-74 2M <br />