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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE,7OFFICE 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 EXPIRESl 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 of the San -Joaquin Local Health District. <br /> JOB ADDRESSttemrm CENSUS TRACT <br /> Owner's Name 4e&r' �1, _{'-y e- Phone <br /> Address s ! d city . <br /> Contractor t s Name �p?°lyl ..� License hone <br /> TYPE OF WORK (Check) : NEW WELL"I DEEP I-7 RECONDITION /-T DESTRUCTION %f <br /> PUMP INST LATION / / PUMP REPAIR-/-7—PUMP REPLACEMENT /7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK�Q SEWER LINES PIT PRIVY ---� <br /> SEWAGE DISPOSAL FIELD -- CESSPOOL/SEEPAGE PIT 4 THER <br /> PROPERTY LINVIP*RIVATE DOMESTIC WELL—' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial /01Cable Tool Dia. of Well ExcavationQ <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing c / <br /> Irrigation Gravel Pack Depth of Grout Seal gg 'd- <br /> Cathodic Protection Rotary Type of Grout .r�. ,H <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor / �► f.S <br /> Type of Pump s,` H.P. <br /> PUMP REPLACEMENT: . /7 State Work Done <br /> PUMP7REPAIR: /7 State Work Done <br /> DESTRUCTION 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 GROUTING AND A FINAL INSPECTIO <br /> SIGNED LE <br /> EnRAIr PL T P ON REVERSE SIDE) u <br /> FOF, DEPAX <br /> TMENT USE ONLY <br /> PHASE I I � y ;7r, <br /> APPLICATION ACCEPTED BY DATE ' <br /> ADDITIONAL COMMENTS: <br /> PHAS M GEM INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY PATE IN PECTION BY - DATE =Z azz A <br /> E H 1426 Rev. 1-74 r 4/75 2M <br />