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_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOr.,OFf CE USE: 1601 E. Hazelton Ave.', Stockton, Calif. ' } <br /> Telephone: (209) 466-6781 l0 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> GSD o <br /> Owner's Name /J Aw,y- (l/�C� c�f �J'f! �'z -------,__�.. Phone 9 � -3 j1/Y <br /> 7^ -,� J� _ <br /> Address �Q dp �C�'/'n�if/ �?� City/ �GLf � • <br /> Contractor's Name 'License �fPhone04��Z fr <br /> I� v. <br /> TYPE OF WORK (Check) : . NEW WELL / / DEEPEN /RECONDITION /_/ DESTRUCTION /_7 <br /> AL <br /> PUMP INSTLATION REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> hy. <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 EL <br /> OMESTIC_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 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: / ./ State Work Done <br /> PUMP .REPAIR: / / State Work Done.. <br /> DESTRUCTION OF WELL: Well Diameter . Approximate Depth <br /> Describe Material and Procedure <br /> 5 <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- wel.l.'construction. Within FIFTEEN DAYS <br /> after completion of myjlwork 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 /> i information is true tolthe best of my knowledge and belief. Z WILL, CALL FOR A GROUT -INSPECTION <br /> -- <br /> PRIOR TO GROU 1NG FIN I gP ECT10N. , <br /> SIGNED "E t TITLE Q /j � --.--'i•1- <br /> I� (DRAW PLOT PLAN ON REVERSE SIDE)- --- , <br /> FOR DEP T USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE I <br /> ADDITIONAL COMMENTS: I� <br /> PHASE` II GROUT- INSPECTION - P - I/FINAL INSPECTION ' <br /> INSPECTION BY IM DATEINSPECTION ,BY DATE <br /> 2M <br /> t E H 1426 Rev. 1--74 _ _. <br />