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""N JOAQUIN LOCAL HEALTH DISTRIC' <br /> T-0-VOFFICE USE: 16(�E. Hazelton Ave. , Stockton, Calm-f. <br /> Telephone: (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <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 /> .nd/or install the work herein described. This application is made in compliance with San Joaqul <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> OB ADDRESS/LOCATION / _��j �� ft « ,y r �� CENSUS TRACT <br /> "wner's Name �Int. Phone a <br /> ,75 <br /> Tddress snOL ", �/-� <br /> City�t�/ I eo <br /> ontractor's Name /t'( &'� u eLlf Ni L�i,b'<� License 4y� Phone�f!S <br /> YPE OF WORK (Check) : NEW WELL /�EEPEN /-T RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR/_7 PUMP REPLACEMENT /_7 <br /> Other /% <br /> .ISTANCE TO NEAREST: SEPTIC TANK 1104,t- 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 /,Z <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> =IeL_ 2rrigation Gravel Pack Depth of Grout Seal C <br /> Cathodic Protection Rotary Type of Grout C <br /> Disposal Other Other Information rn <br /> Geophysical Surface Seal Installed B : <br /> i <br /> 111MP INSTALLATION: Contractor <br /> Type of PumpH.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> wJMPtREPAIR: / / State Work Done <br /> STRUCTION 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 /> id the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> Mer 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 /> iformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> �IOR TO GR ING AND FIN I SPE N. <br /> SIGNED �ti3 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I n FOR DEPARTMENT USE ONLY <br /> 'PLICATION ACCEPTED BY ®1D� DATE <br /> �DITIONAL COMMENTS: �J <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> rNSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br />