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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS OIFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit NoriL7Z� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> In Triplicate) <br /> (Complete P ) <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 l klncr CENSUS TRACT <br /> Owner's Name w d1 r f-' lb ✓ Phone <br /> Address G ! 1,6 City <br /> Contractor's Name as /� License #/fj 7kJj Phone -76.74/ <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPENf / RECONDITION j / DESTRUCTION /-7 <br /> PUMP INSTALLATION j -PUMP PUMP REPAIR /X/ 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 n <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: jk/ State Work Done pd.�>/_rV4 u <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 s <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 k wledg nd belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO TING AND A FINAL EC IQV.i 7/1 <br /> SIGNED ,, TITLE ` <br /> DRAW LOT PLAN ON 4MVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I q r/ <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P S I ' /FINAL INSPECTIQkj <br /> INSPECTION BY DATE INSPECTION BY DATE "'1g <br /> r7 Ce <br /> E H 1426 Rev- 1-7474 <br /> n! <br />