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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466--6781 <br /> F APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. '7f lfl <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. 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 /> JOB ADDRESS/LOCATION <br /> Owner's Name <br /> C CENSUS TRACT <br /> r i <br /> Phone <br /> Address �- City <br /> Contractorts Name License �� kZ2_g4one gI 3 if�� <br /> TYPE OF WORK (Check) : NEW WELL % / DEEPEN <br /> RECDNDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES �j , PIT PRIVY � <br /> SEWAGE DISPO AL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE�CIPRIVATE DOMESTIC WELL ` PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS - <br /> Industrial <br /> _ Cable Tool Dia. of Well Excavation _ <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation g g G <br /> Gravel. Pack Depth of Grout Seal <br /> Cathodic Protection � X Rotary Type of Grout ^� <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B : t <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: <br /> State Work Done <br /> PUMP '.REPAIR: i <br /> /�/ _State Work Done � <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <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 anew well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT 'of the well and notify them before puttingthewell 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 - <br /> .�. £ TITLE ; <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE,-I <br /> FOR DEPARTMENT USE ONLY " <br /> � . <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> DATE <br /> PHA II GROUT IN ECTION PHASE II/F NAL INSPECTION <br /> INSPECTION BY DATE - INSPECTION BY <br /> DATE <br /> E H 1426 <br /> Rev- 1-74 #0 <br />