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' f � <br /> SAN JOAQUIN LOCAL. HEALTH DISTRICT r <br /> FOS:-OFFICE UST-.- 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. /D�7d <br /> -X71 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Al <br /> (Complete In Triplicate) f <br /> Application is tereby 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 t)ijq. San Joaquin Local Health Distrtct. <br /> JOB ADDRESS/LOCATION 4Qe�]'; ! <br /> CENSUS TRACT �J <br /> Owner's Name , Phone <br /> Address city `�1 <br /> Contractor's Name 1 v '� Licensek Phone <br /> a <br /> TYPE OF WORK (Check) : NEW WELL/ J DEEPEN. /% RECONDITION /_7 DESTRUCTION <br /> - PUMP INSTALLATION PUMP REPAIR / J PUMP REPLACEMENT <br /> Other / / "� \0 <br /> s <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 /> 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 <br /> _. ..Cathodic :Protection- .._ -Rota-r-y- -,--Type of•-•Grout--- � <br /> Disposal , ., ' Other Other In€ormation <br /> 4""" ' .Surface',Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump r H.P .- <br /> PUMP REPLACEMENT: .; / / State Work Done <br /> PUMP -.REPAIR: / / State Work Done <br /> DESjRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material. and Procedure <br /> ,4 <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-L <br /> WELL DRILLERS REPORT of the well and notify, <br /> them .before putting the well in use. The above <br /> information is, :true to the best of my knowledge- arid belief. I WILL CALL FOR A GROUT INSPECTION <br />'RIOR TO GROUTING FINAL INSPECTION. <br /> SIGNED TITLE , _ <br /> (DRAW PLOT PLAN ON REVERSE SIDE) , <br /> r <br /> FOR DEPARTMENT- USE ONLY <br /> PHASE I <br /> APPLICATION .ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE ITI/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CO <br /> E H 1426 Rev.. 1--74 <br />