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.01 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F�: CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 d <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 ejtCENSUS TRACT <br /> Owner's Name �� _ ��'��' Phone <br /> Address �� Z� (�` e� �fl�� � City ��6l D/1 <br /> Contractor's Name/"' X50A License JW,4VAtPhoneA4 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ (( RECONDITION /�/ DESTRUCTION /� <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 -C <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK ZIT SEWER LINES PIT PRIVY <br /> 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 /> Industrialy Cable Tool Dia. of Well Excavation <br /> A-- 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 /> 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 GROUTING AND A FIN I SPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY E, DATE J!P 4'"-76' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PH&SE.rWUFINAL INSPECT ON <br /> INSPECTION BY DATE INSPECTION BYNAIMx- <br /> DATE -- <br /> 2M <br /> E H 1426 Rev. - 1-74 <br /> n�77 . <br />