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' <br /> SAN JOAQUIN LOCAL HEALTH DiS'fRIC'f <br /> FOP, OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> `APPLICATION FOR WELL CONSTRUCTION OR FUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued , <br /> i asL- 7 <br /> (Complete In Triplicate) <br /> `pplication 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 Joaqui <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> 'SOB ADDRESS/LOCATION ) 3G ( 1� CENSUS TRACT <br /> rwner°s Name / - t ' (` <br /> Phone <br /> Address - <br /> sibr <br /> City T` <br /> `ontractor's Name /} L 7E ; r'TP License II `Gd /s'6/Phone <br /> 'YPE OF WORK (Check) : NEW WELL DEEPEN /7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION R/ PUMP REPAIRPUMP REPLACEMENT /7 <br /> Other /7 <br /> wISTANCE 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 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> ` Irrigation Gravel Pack Depth of Grout Seal ' s <br /> Cathodic Protection - Rotary Type of Groutj- <br /> -Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: A . - <br /> UMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> "UMP REPLACEMENT: / / State Work Done <br /> TUMP :REPAIR: /7 State Work Done <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> .nd 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 /> "ELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> nformation is true to the best of my krt6wledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING ANDA FINAL INSPECTION,; <br /> SIGNED !: i" TITLE <br /> RE <br /> (DRAW PLOT PLAN ON VERSESIDE) � � <br /> ` FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> PPLICATION ACCEPTED BY DATE -y,/ -]% <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> "NSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br />