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SAN JOAQUIN LOCAL HEALTH DISTRICT 4 <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. �P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -J5 7 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct ,I <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Mules and Regulations of the San Joaquin Local Health District. E <br /> JOB ADDRESS/LOCATIONS I �. CENSUS TRACT17 <br /> E <br /> Owner's Name Phone <br /> Address City G <br /> Contractor's Name Q �� } Slew ^ License #�7 /4/4hone <br />( TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /_/ RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other I I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ` <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER �J <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL Q <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �. <br /> Industrial Cable Tool Dia: of Well Excavation a. <br /> Domestic/private Drilled Dia. of Well Casing 1 <br /> Domestic/public Driven Gauge of Casing F <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: 7- 'I <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: X State Work Done e., �'j _ sl a <br />, PUMP ,.REPAIR: / / State Work Done <br /> f - <br /> 4 <br /> DESTRUCTIO_N_ OF WELL: Well Diameter. Approximate Depth w <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 /> linformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO OUTING AND I FIN INSPECTION. <br /> k SIGNED t - TITLE j e4 ,X 'ii <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> 'APPLICATION ACCEPTED BY 1 I. DATE -2- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FI AL INSPECT I N <br /> INSPECTION BY A I IVE INSPECTION BY DATE <br /> 1/7.7 2M . <br />