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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOArOFFICE 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 1�7b <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local stealth 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. 862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �, (Q � <br /> CENSUS TRACT <br /> �I Owner's Name �7_y6 <br /> Phone _ <br /> Address �x City <br /> Contractor's Name -- _ _ PhoneLicense # <br /> d S <br /> TYPE OF WORK (Check): NEW WELL /? DEEPEN /? RECONDITION /_T DESTRUCTION f7 <br /> PUMP INSTALLATION PCIM REPAIR /� REP&ACEMENT <br /> �ther 7 <br /> DIST CE TO NEAREST: SEPTIC TANK SEWER LINES Qz-o/ IT PRIVY <br /> SEWAGE DISPOSAL FIELD CEPOOL/.SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled q Dia. of Well Casing S <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 By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /7 State Work Done <br /> PUMP `.REPAIR: /7 State Work Done <br /> ES;'RUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and P ocedure <br /> r _ <br /> I reby agre comply with all laws and reg ations of the San Joaquin Local Health District il <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..weli 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 INSPECTION. <br /> SIGNED TITLE <br /> f (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IIIJFINALINSPECTION. <br /> C INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. I-74 1-74 2M <br />