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SAN .JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE 1601 E. Hazelton Ave. , •Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> � s <br /> r � � <br /> THIS PERMIT EXPIRES YEAR FROM DATE ISSUED Date Issued ,6 r <br /> { (Complete In Triplicate) <br /> Application is Aereby made to the San Joaquin Local Health District for a permit to construct' <br /> and/or install the work hereinfdescribed. This application is made in compliance with San Joaquitil' <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br />.TOB ADDRESS/LOCATION ��/�� y�)(� �� �� ,� CENSUS TRACT <br /> Owner's Name Z 1, 0 7-Z Phone ! <br /> Address �� ' r City s�(f, ,/rTGi 9sz1z <br /> Contractor's Name / �' V/•� G. License # (e (j Phone <br /> 1 , <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN /_/ RECONDITION /_/ DESTRUCTION /_7 F <br /> PUMP- INSTAUATION / / PUMP' REPAIR / / PUMP REPLACEMENT <br /> l Other <br /> DISTANCE TO iNEAREST: SEPTIC TANK SEWER LINES PIT PRIVY f <br /> ti <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER r--,--W4 <br /> 4;. 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 Drilled Dia. of Well Casing �! <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal \s; <br /> Cathodic Protection Rotary Type of Grout <br /> Disposals Other.- Other Information <br /> Geophysical `` Surface Seal Installed By:. <br /> PUMP INSTALLATION: Contractor <br /> Type of :Pump H rP-. <br /> PUMP REPLACEMENT: / / StAte Work Done ` u <br /> PUMP .REPAIR: / / State Work Dane <br /> DESTRUCT-ION-_OF WELL;-•...,.Well Diameter Approximate Depth �--- <br />—� .__. /Describe` Material and Procedure <br /> { <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 o€ my work on'a new well, I will furnish the San Joaquin Local Health District a t <br /> WELL DR ERS REPORT of the well and notify them before putting the well in use. The above <br /> informdo is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION ` <br />'RIOR G UTI AND F N NSPE CT ION. <br /> SIGNED TITLE <br /> 7-1 (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE_; °? <br /> ADDITIONAL COMMENTS: <br /> �— <br /> PHASE II T gXPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY z1 DATE INSPECTION BY L/� DATE - r� <br /> 1177 .. 2M <br /> E H 1426, Rev. 1-74 x <br />