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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: (� 1601 E. Hazelton Ave. „ .. Stockton, Calif, c �� <br /> Telephone: (209) 466--6781 <br /> !APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR `.FROM DATE ISSUED " DateIssued �� <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 Ru es and Rye,,gulations. of. the San Joaquin Local Health District. <br /> AVIV”� CENSUS TRACT , <br /> JOB ADDRESS/LOCATION -} C p <br /> Owner's Name <br /> Address"' City &SC A),0,L)_ <br /> k l <br /> Contractor's Name ._ _O Tho IU �]-�onJ __ License # D -0 Phone ,3 - o7 � <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /_/ , DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> J <br /> i 0 ther <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ; <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT. OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> r INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia.� af Well Excavation <br /> t _ <br /> fDomestic/private -.. Drilled Dia.Y of-Well Casing— <br /> Domestic/public Driven Gauge of Casing <br /> k Irrigation Gravel Pack., Depth- of Grout Seal <br /> f Cathodic Protection Rotary Type of Grout <br /> * Disposal : Other Other Information <br /> Geophysical i Surface Seal Installed By : � <br /> PUMP INSTALLATION: Contractor. <br /> Type of Pump <br /> M <br /> PUMP REPLACEMENT: f / 'State Work Done r Tw g ZA <br /> PUMP RMII t w•.. %%"`State. WorkD ne ., <br /> 1 DES-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 /> f and the State of California pertaining to or regulating well •construction. Within FIFTEEN DAYS <br /> G 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. ih -use.. . The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR& GROUT INSPECTION <br /> PRIOR TO GROUTI G AND A Fi4LL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �7�1 <br /> APPLICATION ACCEPTED'.BY ' PJ' DATE 7 �� C d <br /> ADDITIONAL COMMENTS: <br /> PHASE II.GROUT'`�INSPECTI P E /F AL INSPECTION <br /> INSPECTION BY JI# =DATE INSPECTION BY DATE <br /> ` 0/77 _ 2M <br /> E H 1426 Rev. - I-74 I - <br />