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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> _LORQFFIOCE 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 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. 1662 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Al, CENSUS TRACT <br /> Owner's Name b d C73 a Phone <br /> Address .. 0-.2- A,/ City (' co4 ,Zxe�rz <br /> Contractor's Name License # Ak2krffione . c 22! -'�4'7,zf' <br /> TYPE OF=WORK (Check): NEW WELL f/-7 DEEPEN '/7 RECONDITION /-7 DESTRUCTION / <br /> f PUMP INSTALLATION /7 PUMP REPAIRy PUMP REPLACEMENT17 <br /> Other /-7 �1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> he 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 /> �t 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 v <br /> Type of Pump =,k ✓ H.P. 7 r— <br /> PUMP REPLACEMENT: . / ./ State Work Done <br /> PUMP REPAIR: /)�r/ State Work DoneZ 3 <br /> DESTRUCTION OF WELL: Well Diameter v 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 elief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G ANDA YINAL INS zoN. <br /> SIGNED LE ,c ` <br /> ( WsPLOT PLAN ON REV $E SIDE) r <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY F� DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II ROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY _ f� _ DATE <br /> E H 1426 Rev. 1-74 r 4/75 2M <br />