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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE ,CF',�ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -)7 <br /> 1344 <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 5�� ,5�/. �, n� . CENSYS TRACT <br /> WOP <br /> � h <br /> Owner's Name inky /E/l.A4 �ti Phone <br /> Address yf3 s'`14, , City <br /> Contractor's Name License Phone <br /> rn i <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN '/ / RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION/—/ PUMP REPAIR / PUMP REPLACEMENT /-7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 /> Industrial Cable Tool Dia. of Well Excavations <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 /> IN <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: <br /> State Work Done Gl_ v< zz <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 FIFTERN DOTS: <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health DistriPt 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 INSPECTIEN; <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED ` TITLE <br /> W. PLAN ON RiffRSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 7 <br /> APPLICATION ACCEPTED BY DATE 7w& <br /> ADDITIONAL CON HENTS: r <br /> PHASE II NS ECTION PHASE III FINAL INSPECTION , <br /> INSPECTION BY , DATE INSPECTION BY DATE <br /> V76 24 <br /> E H 1426 Rev. 1.74 <br />