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l /SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF,.'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 f6� . <br /> APPLICATION FOR WELL CONSTRdCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE -.ISSUED Date Issued <br /> � . (Complete In Triplicate) <br /> Application is hereby made to the San J6aquin Local Health 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 ana the Rules-and Regulations of the San Joaquin Local Health District. <br /> t JOB ADDRESS/LOCATION CENSUS TRACT <br /> dF <br /> Owner's Name Phone ~_ <br /> Address <br /> City <br /> Contractor's Name License Phone6,?2-y <br /> i TYPE OF.YORK (Check): NEW JLL DEEPEN /7 RECONDITION /7 DESTRUCTION /7 0- <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP. REPLACEMENT /7 <br /> Other iJ / <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER 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 DrilledDia. of Well Casing , <br /> Domestic/public Driven Gauge of Casing We 60 ' <br /> Ii.`ri ation <br /> g Gravef'Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout. <br /> Disposal Other Other Information <br /> Geophysical Strface Seal Installed BY: F <br /> , . <br /> PUMP INSTALLATION: Contractor ' <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT; / / State Work Done <br /> PUMP :REPAIR: 1 <br /> State Work Done - <br /> RES-T WCTION OF WELL: Well Diameter Approximate Depth <br /> ,e-Describe Material 'and Procedure i <br /> I hereby agree to comply with all laws and regulations -of the San Joaquin Local Health District <br /> anti the State of California pertaining to or regulating well •'construction. Within FIFTEEN DAIS <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 /> Ion is rue to the best of my knowledge and belief. I WILL CALL FOR A 'GROUT INSPECTION F <br /> PRIOR TO .GR T G A FINA4 INSPECTION. <br /> SIGNED <br /> TITLE ®IAIYII/r� ' <br /> i , (DRAW,PLOT PLAN ON REVERSE SIDE�� <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: _. <br /> PHASE I GRO T INSPECTION PHASE,!J�/FINAL INSPECTION <br /> INSPECTION BY �✓� DATE �/�7g' INSPECTION BYE DATE —/ <br /> 1 I Nom R.CA1.3 % 2;3G/Pw <br /> E H 1126• Rev. 1-74 puts.,. - �o ►� S 1177 �� <br />