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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209,) 466-6781 p <br /> Y APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �p r <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued, <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 the Sail Joaquin Local Health District. <br /> JOB ADDRESS/?AGA== <br /> l(,CENS US TRACT <br /> Owner's Name 4 ZO; <br /> Phone <br /> Address. City <br /> r <br /> Contractor's Name Y`*ixo ;T License Phone <br /> r i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/ / RECONDITION / / DESTRUCTION /_ <br /> PUMP INSTALLATION /F PUMP REPAIR / J PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK &OkSEWER LINES PIT PRIVY/— <br /> SEWAGE <br /> RIVY —SEWAGE DISPOS IELD `` CESSPOOL/SEEPAGE PIT �_�j OTHE$ <br /> PROPERTY LIN RIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> F WELSPECIFICATIONS <br /> INTENDED USE TYPE OL' `' � ' � CONSTRUCTION SPECIFICATIO S <br /> Industrial Cable Tool Dia. of Well Excavation 2 <br /> Domestic/private 15r: ledDia,of WellLCasing <br /> Domes tic/pub liic ,Driven Gauge of Casing <br /> /Z <br /> Irrigation FGravel Pack Depth of Grout Seal <br /> Cathodic Protection—., Rcf ry Type of Grout <br /> Disposal Other Other Information - <br /> Geophysical -- .° Surface Seal Installed B : <br />?UMP INSTALLATION — _Y_Confractor <br /> TYPe of-'Pump f H.P. <br /> UMP REPLACEMENT: r �it State Work... Done <br />?UMP .REPAIR: / / State Work Done <br />)ES•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> ]]escribe,Materia and Procedure <br /> L hereby agree to comply with all laws and regulations of the Sats Joaquin Local Health District <br /> ind the State of California pertaining to or regulating well "construction. Within FIFTEEN DAYS <br /> ifter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> BELL DRILLERS REPORT of the well and notify them before putting the..well in use.. The above <br /> Lnformation is -true to the best of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />'RIOR TO GROUTING AND A FINAL INSPECTIO <br />)IGNED LE _ M <br /> W L AN ON REVERSE SIDE) j <br /> FOR PARTMENT USE ONLY <br />'RASE I <br /> APPLICATION ACCEPTED BY ,/� DATE <br /> LDDITIONAL COMMENTS: <br /> 9 <br /> P11ME, X G OUT INSPECTION PHA / NAL INSPECTI <br /> LNSPECTION BY DATE 2 17F INSPECTION BY DATE <br /> E..H,1426 Rev. -74 <br /> 1777 2M <br />