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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO :OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. a-13PgP <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the Son 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 Mules and Regulations of the San Joaquin Local Health District. <br /> Cg's.-7 5.-W�'�E I-r:-R T' i�/�� ®`Z I--�� - D k <br /> JOB ADDRESS/LOCATION �`� ' s 7Z CENSUS TRACT <br /> Owner's Name Phone ' <br /> 9 <br /> Address /� a4 City ' ' Y <br /> � s <br /> Contractor's Name �p�,f`,�, ��.,-�� License Phone ��_ <br /> TYPE OF WORK (Check) : NEW WELL/7 DEEPEN /? RECONDITION f7 DESTRUCTION 17 °1) <br /> PUMP INSTALLATION/ j PUMP REPAIR /� 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 m <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation . q <br /> Domestic/private Drilled Dia. of Well Casing �;r_ <br /> Domestic/public Driven Gauge_of Casing __ -,.-'1 <br /> Irrigation = r Gravel Pack v Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information ' ' <br /> Geophysical Surface Seal Installed B i f� <br /> S <br /> PUMP INSTALLATION: Contractor <br /> Type .of Pump o - H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP :REPAIR: F 'w T ^Sfate-Work-Done <br /> k RE TRUCTION _OF WELL: Well Diameter Approximate Depth <br /> 'Describe Material and Procedure <br /> I hereby agreeto 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 /> 4 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 GMTING AND A FINAL INSPECTION. <br /> SIGNED TITLE Crus. <br /> { {DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> ' PHASE I / F <br /> APPLICATION ACCEPTED BY DATE ' <br /> ADDITIONAL COMMENTS <br /> PHASE II GROUT INSPECTION PHASE III ]FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE -�C <br /> r 2M- <br /> E H 1426 Rev. 1-74 -- <br />