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1 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. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issuedrja,2 : j <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 /> j <br /> .JOB ADDRESS/LOCATION d CENSUS TRACT <br /> Owner's Name ?V�'W, . Phone :3^ <br /> LY <br /> ,5,3 <br /> Address S ' : <br /> City 212 �,..��.. <br /> Contractor's Name License # 6 � Phone ]S <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /_/ DESTRUCTION /7 � <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT /7 : <br /> Other /►�/ — <br /> DISTANCE TO NEAREST: SEPTIC TANK 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.. Cable ToolDia. `of Well Excavation _ �y <br /> Domestic/private Drilled n 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 H.P. <br /> PUMP REPLACEMENT /_7 State Work Done <br /> PUMP .REPAIR: / / State Work Done dotL <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> IAhereby 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' b est of my. knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO.GROUTING AND A FINAL INSPECTION. <br /> SIGNED 14&44TITLE <br /> 1-:(DRAW- MOT PLAN 'ON REVERSE SIDES— <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE , <br /> ADDITIONAL COMMENTS: 4 ` <br /> PHASE II GR IN PECTION PHASE /FIN INSPECTION F <br /> INSPECTION BY DATE INSPECTION BY ATE g=Z. <br /> E H. 1426 Rev. 1-74 - 376 2M <br />