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G� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> "0 OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�Jdo <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 Sam Joaquin <br /> County Ordinance No. 1862 an�dth�e- Rules� and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONXkjrr c t,,, -j CENSUS TRACt <br /> Owner's Name Phonel<-2-"7 !Z- L <br /> Address City � <br /> Contractor's Name <br /> `u,l���✓C�Cc, /'.cmc � � License .L ? PhoneJ <br /> ■ aa� <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN /7 RECONDITION /-7 DESTRUCTION f7 - <br /> PUMP INSTALLATION /—/ PUMP REPAIR AO 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 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 INSTALLATION: Contractor �c - <br /> Type of Pump , �, H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: State Work Done <br /> ,SES-TRUCTION 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 thewell 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 GROUTWG AND,A fWAL INSPECTION. <br /> SIGNED TITLE <br /> Q4l1DRAW PLOT PLAN ON REVERSE SIDEQ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY vU! DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II UT I PECTION PHASE III FINAL IN PECTION <br /> INSPECTION BY ` DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 1-74 `2M <br />