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k SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 70-R7OFFICE E: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Permit No. s= � 0—r <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issuedg S 7s <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 Q% / A p!h CENSUS TRACT <br /> Owner's Name �( Phone <br /> Address �''Q" ,�, �LL2�tLL` City <br /> V� <br /> Contractor's Name License #/ ? _' Phone 7 � <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN '/? RECONDITION %T DESTRUCTION /-7 <br /> PUMP INSTALLATION L� PUMP REPAIR/-7—PUMP REPLACEMENT /7 <br /> Other /-7 <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 DO STIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> - c Domestic/private Drilled Dia. <br /> 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 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 "'-V' 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 kn wled nd belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO UTING AND A FINAL I <br /> SIGNED ^ ., TITLE <br /> S&W PrOT PLAN ON WVERsE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> DATE 5 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSP ION PHASE III F INSPECTION <br /> INSPECTION BY DATE INSPECTION BY wJi DATE 77 172 <br /> E H 1426 Rev. 1-74 2M <br />