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✓ SAN JOAQUIN LOCAL HEALTH. DISTRICT (N O�GkL <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif (� "'a'� <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 v?—7 <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 /> 3 ?7? <br /> JOB ADDRESS/LOCATION !.WG?,,rJ ENSUS TRACT <br /> Owner's Name 52 a e2J Phone <br /> Addresszo,�� 11?d City <br /> �G -/W <br /> Contractor's NameLicense � � Phone - Qp <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN/ / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK rjo SEWER LINES _ PIT .PRIVY J <br /> SEWAGE DISPOSAL FIELD CESSPOOL/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 'Q r' G <br /> Domestic/private Drilled Dia. of Well Casing f' <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection )e_ 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: . / / State Work Done <br /> PUMP REPAIR: / / State Work Done`. <br /> DESTRUCTION OF WELL: Well Diameter 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 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 t e be t of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO TING D A JIN INSPECTION. <br /> SIGNED TITLE . <br /> DRAW POT PLAN 'ON RE ERSE SID i " <br /> 10, FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY _ DATE -f -� <br /> E H 1426 Rev. 1-74 " <br /> 3/76 2M <br />