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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOfi;OFFICE USE: 1601 E. Hazelton Ave, , Stockton, Calif. <br /> i <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.��"��p <br /> THIS PERMIT EXPiRHS 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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION S vZ $ I '6C4,610 ,L44 t , CENSUS TRACT <br /> Owner's Name LC w U Phone <br /> Address City: . S4 <br /> Contractor's Name' License # o� 01 Phone <br /> �. _ ?ay <br /> TYPE <br /> OF WORK (Check)~:.y NEW=WELL / ,,T DEEPEN f'7 RECONDITION I'? DESTRUCTION f7 <br /> . x�ts PUMP INSTALLATION L77PUNP REPAIR PUMP REPLACEMPNT /? <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 <br /> Cathodic Protection Rotary Type of Groat <br /> _.. - <br /> Disposal Other Other Information <br /> Geophysical,._ - Siirface�Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. . <br /> l PUMP REPLACEMENT: ' / / State Work Done <br /> . PUMP .REPAIR: 2Y-State Work Done- <br /> , <br /> one- ` <br /> DESTRUCTION OF WELL: Well Diameter Y.Approximate Depth <br /> Describe Material and Procedure <br /> ►'Z 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 <br /> WELL DRILLERS REPORT of the-well­and-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 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 INSPECTION PHAS F NSPECTIO <br /> ' INSPECTION BY DATE INSPECTION BY f DATE 7 G <br /> E H 1426 Rev. 1-74 0M <br />