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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOA OFFICE! USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7zl- //X/o <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. 186 and the Rules and Regulations of the San Joaquin Local Health District. <br /> f <br /> JOB ADDRESS/LOCATION /-/�F✓ QUS/� TRACT <br /> �1 <br /> Owner's Named �t A75 - <br /> ma q Phone <br /> Address //' �� City le�J Gl <br /> Contractor's Name � ���� S LicenseJ � � honeb <br /> TYPE OF WORK (Check): NEW WELL '/ DEEPEN /7 RECONDITION /7 DESTRUCTION f7 <br /> PUMP INSTALLATION /7 PUMP REPAIR /-7 PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <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 <br /> Domestic/private Drilled Dia. of Well Casing <br /> _ Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal F <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B1. <br /> 1 <br /> PUMP INSTALLATION., Contractor <br /> Type of Pump .H.P. <br /> r � <br /> PUMP REPLACEMENT: / State Work Do �/�C <br /> PUMP TREPAIR: /7 State Work Done <br /> ES•TRUCTION 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 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 <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT MSPECTION. PHASE III FINAL INSPE TION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 1_ <br /> E H 1426 Rev. I-74 1-74 2M " <br />�_. x <br />