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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO& OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 �rJ/ye v <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. d <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3 �� <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 /> .TOB ADDRESS/LOCATION Q CENSUS TRACT <br /> Owner's Name Phone �.��/ <br /> Address �G�'� City <br /> Contractor's Name License #,V - `hone 41Z,�§?f �Y <br /> i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION /_% DESTRUCTION /- <br /> PUMP INSTALLATION / / PUMP REPAIR /-7/ PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK _�sL SEWER LINES PIT PRIVY C,►) <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL O <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 149 V <br /> x Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing %L <br /> Irrigation Gravel Pack Depth of Grout Seal / �- <br /> Cathodic Protection �� Rotary Type of Grout ,s <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. J <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP -REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> -- <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 /> 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 SIDE) <br /> FOR DEPARTMENT USE ONLY ITU <br /> PHASE I / <br /> APPLICATION ACCEPTED BYGvDATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT 1INSPECTION P I INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY66eDATE 5---Z , <br /> E H_ 1426 Rev. . 1-74 677 _ 2M <br />