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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601--E. Ha2elton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION -OR PUMP PERMIT Permit No. � <br /> --- -- <br /> Application <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> .. f (Complete In Triplicate) <br /> Application is hereby made tol 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 /> oO <br /> JOB ADDRESS/LOCATION CENSUS TRACT 0" <br /> � <br /> /? r I <br /> Owner's NamePhone <br /> Address City <br /> Contractor's Name - --rLicen'se-##°� 2' Pio e ^ t <br /> 41 t <br /> P, <br /> TYPE OF WORK (Check) : NEW WELL VDEEPEN /_/ RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION—/ I PUMP REPAIR / I PUMP REPLACEMENT 17 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPO FIELD 1 CESSPOOL/SEEPAGE PI7 OTHER <br /> PROPERTY LINE - PRIVATE-DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF ELL CONSTRUCTION SPECIFICATIONS <br /> Industrial able Tool Dia, of Well Excavation <br /> omestic/private Drilled Dia. of Well Casing ` <br /> Domestic/pub.lic 1 Driven -�IwGauge of CasingX � - . -- - k <br /> Irrigation 3 Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary f Type of_ Grout 7U1 <br /> Disposal I Other p- -Other. Information <br /> _Geophysical "Surf ace Seal- Ins tailed- B <br /> �. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump i H.P. <br /> i f � <br /> PUMP REPLACEMENT: : f / State Work Done; �.._,. -. _- -- -= <br /> PUMP 'REPAIR: State Work Donel <br />!2ESzTRUCTION- OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> fI hereby agree to comply with! all laws and regu ations 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 be t of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU G AND- A FIqA INSPECTION. <br /> SIGNED zqimg, { TITI e>�} <br /> (DRAW KLOT PLAN ON REVERSE SIDE) <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED-BY <br /> -,. .�_.... ...DATE. <br /> ADDITIONAL COMMENTS. <br /> PHASE II GROUT INSPECTION PHASE I I/FINAL INSPECTION <br /> : INSPECTION BY DATE ".INSPECTION BY ATE <br /> 1177 2m <br /> E H 1426 Rev. 1-74 <br />