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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR76FFICE 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 0- 5 <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/LOCATIONL CENSUS TRACT <br /> Owner's Name fi r_sa , �r° a�° <br /> � Phone <br /> Address � �� G�/ .� ,�. City ° d <br /> Contractor's Name License &go ZY `Phone <br /> TYPE OF WORK (Check): NEW WELL /�DEEPEN -7 RECONDITION /7 DESTRUCTION f <br /> PUMP INSTALLATION PUMP REPAIR /-7-pump REPLACEMENT %7 <br /> Other /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK e) SEWER LINES PIT PRIVY <br /> SEWAGE DISPO AL FIELD CESSPOOL/SEEPAGE PIT 1p D OTHER <br /> PROPERTY LINE —PRIVATE DOMESTIC WELLPUBLIC 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 BYE_ <br /> PUMP INSTALLATION: Contractor e2e- <br /> Type of Pump , ° ,f esa H.P. <br /> PUMP REPLACEMENT: / /T State Work Done <br /> Ptd.REPAIR: /? State Work Done <br /> JDES TRU`ON 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 t e well and notify them before putting thewell in use.. The above <br /> information is tru o t e best ,,,,o_. owle and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GIIICT <br /> IN ` <br /> SIGNED y „�, ► TITLE <br /> DRAW PLOT PLAN ON REV IDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY t�s. f DATE <br /> ADDITIONAL COMMENTS: �*T' <br /> P� � <br /> ,E II OU INSPECTION PHAS I F AL INSPECTY N <br /> INSPECTION BY9 F .DATE &h INSPECTION BY ATE <br /> E H 1426 Rev. 1-74 1-74 2M <br />