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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOB:OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PE mILNo. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued7j <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 Sf, n Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONN �- _ .F- 94"; ), CENSUS TRACT <br /> •w w.ww <br /> Owner's Name ,� ��/ �( <br /> Phone �� V- 7 2-3 <br /> Address Gam. L-ci,( -ems City <br /> Contractors Name License #1( 23 7-3 PhoneY j-j <br /> TYPE OF WORK (Check): NEW WELL/-7 DEEPEN '/-7 rRECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION/ / PUMP REPLACEMENT 17 <br /> Other /-7 <br /> .._ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC LL' 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 Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLdT7. �Ctorg. <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 /> 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 /> informati tr a to the-best of knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TOG IN AND NAL INSP ION. ®7„ <br /> SIGNED TITLE <br /> RAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE T <br /> APPLICATION ACCEPTED BYDATE 2- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTIwr <br /> INSPECTION BY DATE INSPECTION B 17Gt, DATE <br /> E H 1426 <br /> Rev. 1-14 2M <br />