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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOR-OFFICE USE: ' 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> �. <br /> Telephone: (209) 466--6781 '� � <br /> 1 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued V,2 <br /> (Complete In Triplicate) <br /> 'T <br /> Application is Aereby 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 Joaquin <br /> County Ordinance No. 1 62 and the Rules and Regulations of the San Joaquin Local. Health District. <br /> a fj. <br /> JOB ADDRESS/LOCATION .'° CENSUS TRACT (?0: 3r0 oaf <br /> Owner's Name Phone <br /> Address77 sl <br /> City <br /> s � <br /> Contractor's Name License 4� hone <br /> /I- Izzma <br /> TYPE OF WORK (Check) : NEW WELL /-7 DEEPEN /_/ RECONDITION /_� DESTRUCTION <br /> AL <br /> PUMP INSTLATION 15e-17PUMP REPAIR / / PUMP REPLACEMENT /? <br /> Other <br /> N y <br /> 3 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY I"F� <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL r <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 <br /> Disposal Other Other Information <br /> Geophysical -_� Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. "t <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: f / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health istrict <br /> and 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 /> information ue to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G G ARD A FINAL INSPECTION. <br /> SIGNED [ TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIA <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY <br /> E H 1426 Rev. 1-74fI7 <br />