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Ze_A <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR•rOFFICE USE: 1601 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 /O-7V, <br /> (Complete In Triplicate) <br /> Application is hereb 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 San Joaquin Local health District. <br /> JOB ADDRESS/LOCATION f I gip- 3 CENSUS TRACT <br /> Owner's Name <br /> Phone -f Eel z , <br /> Address City Er e c.4 <br /> Contractor's Name -NI 0, C - License ffJ7Phoae�//, 2Y <br /> TYPE OF WORK (Check): NEW WELL/W DEEPEN /_7 RECONDITION /7 DESTRUCTION (7 <br /> PUMP INSTALLATION j—/ PUMP REPAIR /-7—PUMP REPLACEMENT /—f <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK,3� SEWER LINES ,ion y- PIT PRIVY <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 /p 1/ <br /> - Domestic/private Drilled Dia. of Well Casing tl� <br /> Domestic/public Driven Gauge of Casing /(,0 .. Or <br /> Irrigation � Gravel Pack Depth of Grout Seal <br /> Cathodic Protection V Rotary Type of Grout' <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed- AX: �-77r.". „_ a <br /> ,. 1 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump -- • - H.P. <br /> PUMP REPLACEMENT: Ll State Work Done <br /> PUMP,!REPAIR: /7 State Work Done _ <br /> ES:TRUCTION 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 <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 GRO. ING AN FINAL SPECTIAN. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ��}} <br /> APPLICATION ACCEPTED BY N.�l� E DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS III FINAL INSPECTION <br /> INSPECTION BY DATE a-Il��l� INSPECTION BY DATE <br /> '4 E H 1426 Rev. I-74 <br />