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i' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO"fOFFICE USE: l'" 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> :43 ro APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 7—�---9� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED -Date Issued 2-19-17_5_ <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 rade in compliance with SanJoaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San;Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION [, �. � �� „ CENSUS TRACT <br /> Owner's Name ./' � �,✓�� � �'4 ���°�.�" C-..�� Phone <br /> ,�. /'f <br /> Address ,��'� � � f, ��� City <br /> Contractor's Name r License #-hr4 9Sf Phone 144"6F6 <br /> TYPE OF WORK (Check): NEW WELL DEEPEN/_7 RECONDITION /7 DESTRUCTION /—j <br /> PUMP INSTALLATION j< PUMP REPAIR /_7 PUMP REPLACEMENT,,, /7 <br /> Other /% <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPO AL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL Z.L DOMESTIC <br /> PUBLIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 47� <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 <br /> Geophysical Surface Seal Installed BY: <br /> T <br /> PUMP INSTALLATION: Contractor ` ' <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP:REPAIR: /7 State Work Done <br /> ,j2ES TRUCTION 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 tide,to the-best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR -A l S (.TION. <br /> SIGNED <br /> .�'' .. , �, ,�'� � TIT <br /> (DRAW PLOT PLAN ON REVERSE S__._ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> P ROT INSPECT N PHAS III IN INSPECTION <br /> INSPECTION BY - - INSPECTION BY DATE <br /> } E H 1426 Rev. 1-74 1�M <br />