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iT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOL,OFFTCE USE: 1601 E. Hazeltori;;�Aveti Stockton, Calif. <br /> Telephone: {209 ) 4.66-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued g ?� <br /> AppllcaCion is 11 (Complete In Triplicate) <br /> 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 Ruse and Regula Eons the fan Joaquin•Locel Health District. <br /> JOB ADDRESS/LO ON <br /> _�Y3­7 CENSUS-TRACT <br /> -TTRACT <br /> Owner's NameGly'1,E1 7- Phone <br /> Address <br /> f Contractor's Name -� � � jCity <br /> License #7��373Phone 4/ .�,b45e ' <br /> _ _ -. - . _ _ <br /> TYPE OF-WORK (Check); NEW WELL /1. DEEPEN f_ RECONDITION / DESTRUCTION. <br /> PUMP INSTALLATION / / PUMP REPAIR '/ PUMP REPLACEMENT / f <br /> Other /% — <br /> DISTANCE TO NEAREST': SEPTIC TANK EWER LINES PIT PRIVY <br /> SEWAGE DISPO AL FIELD CESSPOOL/SEEPAGE- PITOTHER <br /> PROPERTY LINE - PRIVATE DOMESTTC WELL -� PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELT, `` � CONSTRUCTION Dia. of Well Excavation SPECIFICAT NSoW <br /> Industrial ., Cable T (' <br /> ✓Domestic/private aal Drilled Dia. of Well Casing W <br /> IrrigatioDomestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack, Depth of Grout Seal <br /> Cathodic Protection ✓- RoCary Type of Grout , <br /> Disposal Other <br /> ' Other InformaCion ' � <br /> Geophysical - Surface Seal Inata d f <br /> t <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: <br /> State Work Done <br /> PUMP .REPAIR:- State Work Do <br /> - _-.....r..�._ _- . . la� r fi <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 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. <br />?RIOR TO I WILL CALL FOR A GROUT INSPECTION <br /> GROLtTING AND. A FINAL INSPECTION. { <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON- REVERSE SIDE <br /> PI€AST:,I FOR DEPARTMENT USE ONLY <br /> UPLICATION`•ACCEPTED'BY <br />?ADDITIONAL <br /> COMMENTS: DATE <br /> PHASE I GROUT INSPECTION <br /> INSPECTION BY PHAS II FINAL INSPT:CTIO <br /> DATE 9 INSPECTION BY DATE 7 <br /> E H 1426 Rev. 1-74 <br />