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SAN JOAQUIN LOCAL HEALTH DISTRICT 1 <br /> F_W OFFICE 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 <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 <br /> of. rhe San Joaquin <br /> � Local Health District, <br /> f "JOB ADDRESS/LO TION , �' f / "` CENSUS -TRACT <br /> i <br /> Owner's Name y 22c Phon�3 67 ! <br /> Address�6Ok� ��".� City31- <br /> 4License ���2�hone <br /> Contractor's .Name <br /> t <br /> TYPE OF WORK (Check): NEW,WELL -/7 DEEPEN /7 • RECONDITION /_T" DESTRUCTION <br /> AL <br /> PUMP INSTALLATION /� pulp REPAIR PUMP REPLACEMENT /? <br /> Other / <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 Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> i PUMP REPLACEMENT: / / State Work Done <br /> PUMP :PAIR: �.�-State Waxk Da <br /> tel. _ . <br /> &ES;TRUCTION OF WELL: Well Diameter Approximate Depth w <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> kand 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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I464tll, <br /> � <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> k INSPECTION BY DATE INSPECTION BY DATE <br /> ' <br /> 1-7 4 2M <br /> E H 1426 Rev. 1-74 <br />