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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 /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued7� <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 th ules anddRegt�lations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Namea"�f'-� J` • Phone <br /> Address �® "" {/ City <br /> ' ` } License f�"237�hone`/d6�4—` <br /> Contractor s Name <br /> TYPE OF WORK (Check) : NEW WELL '/-7 DEEPEN/ / RECONDITION / / DESTRUCTION /-7AL <br /> PUMP INSTLATION/ / PUMP REPAIR PUMP REPLACEMENT /7 <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 7 <br />€ Domestic/public Driven Gauge of Casing <br /> EIrrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection 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; /-7 State Work Done <br /> PUMP .REPAIR: _` State Work Dore ' - - <br /> k <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 the-best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING. AND A FINAL INSPECTION. <br /> SIGNED V, TITLE ,,,a1 -,,�- <br /> " D W PL T PLAN"ON REVERSE SIDE) , k <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I � �— <br />' APPLICATION ACCEPTED_ BY DATE <br /> ADDITIONAL COMMENTS'. ' ' <br /> PHASE Il GROUT. INSPECTION PHASE T I/ INAL INSFEC IO <br /> INSPECTION`BY. DATE INSPECTION BY I� DATE � <br /> 3/7 <br /> E H 1426 Rev. 1-74 <br />