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SAN JOAQUIN LOCAL HEALTH DISTRICT -- <br /> FOA!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•YEA,R 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 :Wade in compliance with San Joaquin <br /> County Ordinance -No. 1862and a Rules and Regulations San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �� -c-'-_'��'L-CENSUS TRACT <br /> Ownerss Name Phon 'r-4y <br /> Address L �} I� GUl ��a y �' JC: Or � <br /> Contractor's Kama � � License �7ihone5'���� _ <br /> - ...._. <br /> TYPE OF WORK (Check): NEW WELL L7 DEEPEN 17 RECONDITION /7 DESTRUCTION Lf y' <br /> PUMP INSTALLATION L� PUMP REPAIR /7 PUMP REPLACEMENT <br /> Other /7 <br /> f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> t SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE RREST.IC 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 B : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump R.P. <br /> PUMP REPLACEMENT: / State Work D14 <br /> PUMP :REPAIR: r -L7- -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 FORA GROUT INSPECTION <br /> PRIOR TO GROUTING-AND 'A FINAL INSPECTION. <br /> SIGNED ' TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) r' <br /> FOR DEPARTNENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .BY, DATE 9!t/ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHO_2� 1.jyygINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE , <br /> „E H 1426 Rev. 1-74 <br />