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v �N JOAQUIN LOCAL HEALTH DIST)PIC <br /> FOR OFFICE USE: /�=16�Y E. Hazelton Ave. , Stockton, CaZ'if. <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) <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 Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> -0B ADDRESS/LOCATION n,) a/; ,) ,y 411L_ CENSUS TRACT <br /> owner`s Name �[ �P.,S [ t H Phone <br /> Address A,-rnj- i) City <br /> ontractor's Name _Td? �, ,� `��cC J License # ,�79n7r., Phone <br /> 'YPE OF WORK (Check) : NEW WELL / / DEEPEN /_7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION /V PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / / <br /> )ISTANCE 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 <br /> Cathodic Protection Rotary Type of Grout r <br /> —Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> ^UMP INSTALLATION: Contractor S,, T%DA/ <br /> Type of Pump j H.P. / a� <br /> PUMP REPLACEMENT: / / State Work Done <br /> 'UMP .REPAIR: /% 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 /> ind 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 /> .nformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> -RIOR TO GRO TING AND FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> F EPARTME T USE ONLY <br /> PHASE I <br /> 'iPPLICATION ACCEPTED Zah22 VALI&O-LIDATE 23",hs <br /> DDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FIAL INSPECTION <br /> ?NSPECTION BY DATE INSPECTION BY ' DATE -> <br /> tz , <br /> E H 1426 Rev. 1-74 _ i. <br />