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SAN JOAQU:IN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. " 'rs <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Ie <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 /> Owner's Name —� <br /> Phone �� 441 5— <br /> Address _ /� /�✓�a City <br /> Contractor's Name r License fl57Xhon z <br /> TYPE OF WORK (Check) : NEW WELL /C�- DEEPEN / RECONDITION / / DESTRUCTION /i7 <br /> PUMP INSTALLATION / UMP REPAIR /-/-PUMP REPLACEMENT /-T ot+ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK /,:9e.>-/-SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD /6--,o OfCESSPOOL/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 19 da <br /> v--Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 4;2 <br /> Irrigation Gravel Pack Depth of Grout Seal _ ce <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 /> 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 belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO ING D A FINAL INSPECTION <br /> ev <br /> SIGNED TITLE <br /> (DRA PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE = ---f--'� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION Vz <br /> PHASE III/FINAL INSPECTION�� �5 <br /> INSPECTION BY DATE INSPECTION BY������� "DATE <br /> � <br /> E H 1426 Rev. - 1-74 <br /> 6, 77 <br />