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SAN JOAQ N LOCAL HEALTH DISTRICT <br /> FOH OFFICE USE,; 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <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 /J2 Cfn A O1T e d CENSUS TRACT <br /> Owner's Name a�1�'t ``2=—i '1Y�'� � Phone 9'1/$ -41622 <br /> Address )I bc?!a City! <br /> Contractor's Name 16 _ License Phonejau dA <br /> ZE <br /> r <br /> i <br /> TYPE OF WORK (Check) : NEW WELL JK DEEPEN/ / RECONDITION / / DESTRUCTION /- <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /- <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 Q) <br /> Industrial Cable Tool Dia. of Well Excavation /- <br /> Domestic/private Drilled Dia. of Well Casing lit <br /> Domestic/public Driven Gauge of Casing A <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 t <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 />?RIOR TO GROUTING AND A FINAL INSP CTION. <br /> SIGNED TITLE <br /> (PRAWP4AkT PLANYODN REVERSE SIDE) <br /> FQR EPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 2 <br /> ADDITIONAL COMMENTS: <br /> PHASE II G ON PHASE III/FINAL INSPECTION <br /> INSPECTION BY 4 46ZtA7 INSPECTION BY A DATE �?.� = <br /> E H 1426 Rev. 1-74 1I?/ 214 <br />