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h f/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOSS 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;7,i�_9a-9.d <br /> { -76 Complete In Triplicate) lP 6 <br /> Application is hereby made to the Sart 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 Joaquit <br /> County Ordinance No. 186 nd the es and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone <br /> Address ep z Cisme-� <br /> �� City <br /> Contractor's Name License <br /> TYPE OF WORK (Check): NEW WELL "L_'�"DEEPEN ./7 RECONDITIONL7 DESTRUCTION /_7 <br /> PUMP INSTALLATION /[ UNP REPAIR -/_7 PUMP REPLACEMENT r7 <br /> Other /% -- <br /> DISTANCE TO NEAREST: SEPTIC TANK 7 6' 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 able Tool Dia. of Well Excavation <br /> 41Domestic/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 f <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP REPAIR: / / State Work Done ' <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <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 DRILIrERS REPORT of the well and notify them before putting- the-well <br /> in-use.. The above <br /> information is true to the-best of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />?RIOR TO GRnTITTMn AND A FINAL INSPECTION. <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY * DATE <br /> ADDITIONAL COMMENTS: <br /> PtA II OUT INSPECTION PHA III FINAL INSPECTION <br /> INSPECTION BY DAT$ D z 7� INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br />