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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO­R,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �S 39a4v <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 I1ealth 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 the Sacs Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION J j CENSUS TRACT - <br /> Owner's Name 7-z{, cc� Phone <br /> Address City " <br /> Contractor's Name License #7 X42 Phone `_I z 7 <br /> TYPE OF-WORK K(Check); NEW WELL T DEEPEN '/_7 TRECONDITION /_7 DESTRUCTION /7µ <br /> PUMP INST LLATION / / PUMP REPAIR -/ PUMP REPLACEMENT L-7 , <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> i SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY.LINE PRIVATE"DOMESTIC WEtii ; ' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> -} Industrial _ Cable Tool Dia.!of Well Excavation <br /> kDomestic/private Drilled Dia. `of Well Casing � <br /> Domestic/public Driven Gauge of Casing , 4 <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 4 <br /> Type .of Pump H.P. " <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> - _ — <br />} 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 /> 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 FOR A GROUT INSPECTION <br />? PRIOR TO G UTING AND A VIN4 INSPECTION. ) <br /> SIGNED TITLE'" <br /> i <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> i FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED DATE ,C <br /> ADDITIONAL COMMENTS: <br /> i PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYi(a% DATE <br /> T <br /> t E H 1426 Rev. 1-74 - - - -- - 4/7�,- 2M <br />