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. SAN .JOAQUIN LOCAL HEALTH DISTRICT � <br /> FORiOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ' <br /> Telephone: (209) 466-6781 <br /> APPLICATION voR WELL CONSTRUCTION OR PUMP PERMIT Permit No. z <br /> THIS PERMIT EXPIRES 1-YEAR FROM DATE ISSUED Date Issued X76 <br /> 1 . -(Complete In Triplicate) <br /> Application is hereby made to L•he 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 the San Joaquin Local Health District. <br /> JOB ADDRESS/.LOCATION / <br /> CENSUS TRACT <br /> Owner's Name __Lf, 6CA2Phone <br /> Address 4 cLA City a,� <br /> 3 VS-4 <br /> Contractor's Name S License hone Syq- <br /> TYPE OF WORK (Check): NEW WELL '/� DEEPEN -/7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION jFe7 PUMP REPAIR /L PUMP REPLACEMENT._.f f - <br /> Other <br /> � d <br /> DISTANCE TO NEAREST: SEPTIC TANK '-1SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD `` CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL 0 <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 <br /> PUMP INSTALLATION: Contractor` � S ..��io;��. �= �� CI <br /> Type of Pump act 0 ri H.P. <br /> PUMP REPLACEMENT: /-7 State Work Done <br /> PUMP !REPAIR: /7 State Work Done _ <br /> - _. . 16. .- _ _ -- <br /> _RUCTION 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 District <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 p` <br /> WELL DRILLERS REPORT of the well and notify them before putting-the- well in-use.. The above # <br /> information is true to .the best of my knowledge and belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. i <br /> SIGNED .,-- TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) , <br /> PFOR DEPARTMENT USE ONLY <br /> HASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION / <br /> INSPECTION BY DATE INSPECTION. BDATEaz <br /> E H 1426 Rev. 1-74 1-74 2M <br />