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• ,. _ / SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: k" 160`1 E. Hazelton Ave. , Stockton, Calif. ; <br /> Telephone : (209) 466-6781 ' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �77 <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 jkegulations of the San Joaquin Local Health District. <br /> .} <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name <br /> Phone �✓ ti C7 <br /> � �. <br /> Address 0 City �07/ Ka, <br /> Contractor's Name '� License # Phone <br /> �i <br /> TYPE OF.WORK (Check) : NEW WELL '/ / DEEPEN /_/ RECONDITION %./ DESTRUCTION 1-7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR/�fl/ ?UMP REPLACEMENT49 <br /> Other <br /> 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PITvPRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> 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 a <br /> P Drilled Dia. of Well lasing �{ <br /> Domestic/public { Driven Gauge of Casing �1 <br /> Irrigation Gravel Pack Depth of Grout;Seal <br /> Cathodic Protection Rotary Type of Grout <br /> ]Disposal i Other Other Information <br /> -Geophysical _ N � . ,. <br /> Surface Seal Installed B <br />'UMP INSTALLATION: _. Contractor J b • - <br /> TYpe of Pump �� ! H.—P. <br /> s <br />'SUMP REPLACEMENT: / / StaietWLor k1,Done � ,, , <br />'UMP .REPAIR: <br /> /_•/�Siete Work Done <br /> z <br /> ES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 1 <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> end 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 /> TELL DRILLERS REPORT of the well and notifythem before ore putting the well in use. The above <br /> nformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> RIOR TOG UTINGFI AL IN CTION. i <br /> IGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> HASE I <br /> PPLICATION ACCEPTED BY t DATE <br /> DDITIONAL COMMENTS: , <br /> PHASE II GROUT INSPECTION PHASE T I FINAL INSPECTION <br /> NSPECTION BY �., DATE INSPECTION PATE 7- 1Z, 7 <br /> _E H 1426 Rev. 1-74 <: If7 7 2M <br />