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i SAN JOAQUIN LOCAL_ HEALTH DISTRICT /AFF 86.Lam, J <br /> FOF OFFICE USE: y -,1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 / <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7 7-, 6c,GC[� <br /> THISIPERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued _ f <br /> (Complete In Triplicate) <br /> Application 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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of t e San Joaquin Local Health .District. <br /> � i <br /> JOB ADDRESS/LOCATIONLrV 4CENSUS TRACT <br /> Owner's Name PhoA <br /> Address t <br /> Contractor's Name c # �G4f—, one <br /> i <br /> TYPE OF WORK (Check): NEW WELL DEEPEN / RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION / PUMP REPAIR/ / PUMP REPLACEMENT f <br /> Other 1_1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPIOU FIELD CESSPOOL/ EP GE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPEOF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial , Cable Tool Dia. of Well Excavationf <br /> Domestic/private Drilled Dia.. of Wel-1 Casing <br /> Domestic/public Driven Gauge of Casing lie <br /> TIrrigation 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: &State <br /> �►' <br /> p <br /> Worc onePUMP REPLACEMENT; , <br />'PUMP :REPAIR. _ State Work Dane <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 bistrict <br /> Ad 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 DRILLE REPORT well and notify them before putting the well in use. The above <br />; informatio is true to the est of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G G AN A F .INSPEOTION. <br /> SIGNED TITLE _ OuEu-� p l% AL <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR TARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE12_?1L_ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE, I /FINAI INSPECT <br /> INSnECTION BY DATE _ / " INSPECTION BY4241 <br /> 1fJ <br /> E H 1426 Rev. 1-74 <br />