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SAN JOAQUIN LOCAL.HEALTH DISTRICT <br /> FOF 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/.�- <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. T4.s application as made in compliance with San Joaquin' <br /> County Ordinance No. 1862 and the ,RuleX).a d Regulations of the San Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION r _ �,. 4WqgCENSUS•TRACT <br /> Owner's Name t" Phone <br /> Address 3 �.0 7-a.�i City '-_J 7-2!z 1-A 7�zn� <br /> Contractor's Name r License #a4_S'761 Phone A <br /> I <br /> TYPE OF WORK (Check) :a NEW_ WELL / /. .DEEPEN ../ / RECONDITION /„_/_DESTRUCTI0N._/_7 <br /> } PUMP INSTALLATION /C../ PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK jet`+ SEWER LINES ��ti� PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CE SS POOL/SEEPAGE PIT _ OTHER <br /> PROPERTY LINEWFRIVATE DOMESTICr:WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing '. <br /> Irrigation Gravel Pack- e Depth of Grout Seal <br /> Cathodic Protection Rotary "Type of Grout <br /> Disposal Other ` Other Information " r <br /> .f Geophysical Si dace Seal Installed By: <br /> PUMP ,INSTALLATION: Contractor ` ` <br /> v ei / C. <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> r _ <br /> PUMP .REPAIR: / / State Work Done <br /> T <br /> DESTRUCTION OF WELL: Well .Diaiieter Approximate Depth <br /> Describe Mater-ial: and_P-r-ocedure. --m--- - <br /> I hereby agree to comply with all laws and regulations of the San, Joaquin Local Health District i <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 i <br /> WELL DRILLERS REPORT of the well and notify them before putting thewell in use. , The above i <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 /> - (DRAW PLOT PLAN ON REVERSE SID ) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS INSPECTION ' <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> of%7 2M 1 <br /> E H 1426 Rev. . 1-74 _ �.�„ a <br />