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ezf SAN JOAQUIN LOCAL HEALTH DISTRICT JA <br /> FO 70FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l 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/LO TION �)� <br /> CENSUS TRACT <br /> Owner°s Name Phone �7` f <br /> Address �'� Pd-z' Ci 'z'� s-�� <br /> Y <br /> Contractor's Name ZA2KI 0G D PJB <br /> "�� License 3 hon���J���-- <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN "/_7RECONDITION' / 7 DESTRUCTION %j <br /> PUMP INSTALLATION' PUMP REPAIR 0 PUMP REPLACEMENT 1-7 <br /> Other / f — <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 V <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 Grout <br /> Disposal __ Other __ Other Information 0 <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: f7_ State Work Done <br /> PUMP :REPAIR: 17 State Work Done <br /> E&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 t <br /> ove <br /> information is true to the-best-of- my knowledge and beliefttii WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE l ' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �/ : <br /> DATE 2-9 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III INAL INSPEC -IO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 <br />' Rev. I-74 <br />