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/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORfOFFICE USE: VV 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 4666781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> _ THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> ( implete In <br /> Application is hereby made to the San Joaquin Local Health District f <br /> oa pe it. This application is made inrcompliancetwithn <br /> and/or install the wank herein describedSan Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the Sari Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 3S-4r <br /> KIAZ CENSUS TRACT <br /> 3 Owner's Name <br /> !:4 r_r Phone <br /> Address <br /> City <br /> Contractor's Name .,: •' <br /> r r c ti„ <br /> License-#--Phone _ <br /> f TYPE OF WORK (Check): NEW WELL 'ZX DEEPEN/� RECONDITION /? DESTRUCTIONS <br /> PUMP .INSTALLATION <br /> If / / PUMP REPAIR /� PUMP REPLACEMENT /7 <br /> f Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY t LINE M PRIVATE DOMESTIC WELL ' "' ' PIS�C_DOMESTIC WELL <br /> TYl INTENDED USE . PE OF WELL y � ' ;CONSTRUCTION SPECIFICATIONS � ` <br /> Industrial `� ; <br /> f Cable,Tool Dia. ofiWe'll Excavation `�_ <br /> Domestic/private Drilled Dia. ofWell-Casing <br /> Domestic Driven + <br /> '­-_Irrigationublic ; Gauge of Casing <br /> Gravel Pack Depth of Grout Se l y <br /> Cathodic Protection Rotary. '-' rT3,p af `Grout ` <br /> n <br /> Disposal Other .;. Other Informatio <br /> Geophysical Surface Seal Installed By: <br /> i <br /> TA <br /> PUMP INSLLATION: 'Contractor.. <br /> Type of Pump -�+ .�. # <br /> P <br /> A . <br /> H. <br /> PUMP REPLACEMENT: V <br /> / / Stats Work.Done-� <br /> PUMP :REPAIR: '" ' <br /> 1-7 State Work Done I. <br /> ES;TRUCTION OF WELL: Well 'Diameter <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply with all laws and regulations of the an Joaquin Local Health District <br /> and the State of California pertaining to or regulating well, construction. Within FIFTEEN DAYS j <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 TOG UTING AND INAL INSPECTION. <br /> SIGNED <br /> TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE ; <br /> _PHASE I FAR DEPARTMENT USE ONLY / <br /> APPLICATION ACCEPTED BY (2DATE/f/3/J/ <br /> ADDITIONAL COMMENTS: d <br /> PHASE 11- GROUT INSPECTION PHAS II FINAL INSPEC N <br /> INSPECTION BY DATE INSPECTION. BY � 7j <br /> DATE <br /> E H 1426 Rev. 1-74 • � <br />