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Z USAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOfi OFFI E USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. .:Z -7,W �0 <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 S Q'� � f to rnU►r /� /,,,o r�b d a{i✓ta Fitat, CENSUS TRACT <br /> Owner's Name Qy e� lJPhone <br /> Address ! 3 3 �..� - c./a�,� <br /> �.��- .. City <br /> Contractor's Name <br /> G License # 4ft2s4'"Phone <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN /7 RECONDITION /? DESTRUCTION f7 <br /> PUMP INSTALLATION f-1 PUMP REPAIR-1-7 PUMP REPLACEMENT <br /> Other J% <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 <br /> 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 G G AND A FINAL INSPECTION. _ <br /> SIGNEDo u)�LiTLE <br /> (DW PqLT PLAN ON SE SIDE <br /> PHASE I DEPARTMENT USE ONLY <br /> APP IL�CATION ACCEPTED BY DATE 3 <br /> ADDITIONAL COMMENTS <br /> PHASE II GROUT 116PECTION PHASE III FINAL INSPECT ON <br /> INSPECTION BY DATE INSPECTION BY DATE I a4174 <br /> E H 1426 Rev. 1-74 2M <br />