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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE:OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,Zlz-�T�.�� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued g,�-2Z <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/LOCATIONI C�-Al CENSUS TRACT <br /> Owner's Name � ,, ' e `E" `r ' Phoned f <br /> Address ?t / <br /> City �a� <br /> f <br /> Contractor's Name License y�J�PhontTZJ <br /> 1,�' <br /> TYPE OF WORK (Check): NEW WELL gr--DEEPEN ,/`7' RECONDITION /7 DESTRUCTION f_7 <br /> PUMP INSTALLATION /7 PUMP REPAIR/_7 PUMP REPLACEMENT /7 <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISP SAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ale Tool Dia. of Well-'Excavation JIf (� <br /> L—*" omestic/privata Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing E? <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 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT Ll State Work Done <br /> PUMP ,REPAIR: /-7 State Work Done <br /> DES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure t <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. With6 FIFTEEN DAYS <br /> after completion of my work on 'a new well, I will furnish the San quin. 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 FOA A GROUT INSPECTION <br /> PRIOR TO GR ING AND A FINAL INSPE I . <br /> SIGNED TITLE t mow. <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE i n <br /> APPLICATION ACCEPTED BY DATE �� Z d / <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION, PHASE III FINAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY DATE /o / <br /> E H 1426 Rev. 1-74 4175 2M <br />