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SAN JOAQUIN LOCAL REALTH DISTRICT <br /> 0 OFYICE USE: ' 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--67$1 <br /> ' APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. C / <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued. L_1S 7 <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 7 G fs_ ; ; W -: CENSUS TRACT <br /> Owner's Name <br /> Address i:it <br /> Contractor's Name I..icense # # P s Phone :. <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION-/—/ DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR /�C/ PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK--SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEFPAGF PIT__ __ _ OTHER _ <br /> PROPERTY LINE -• PRIVATE DOMESTIC WELL --_ PUBLIC DOMESTIC WELLo <br /> INTENDED USE TYPE OF WELT. CONSTRUCTION SPECIFICATIONS <br /> Industrial � Cable Tool Dia. of Well Excavation --�_-� <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 /> PUMP INSTALLATION: Contractor. <br /> Type of Pump r 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 Sart 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 /> PRIOR TO ROU ING ANDA FINAL 1NSPEC.TION .. <br /> SIGNED j „TITLE <br /> RAWjL1j0T_?T2N1 ON RE kSE SIDE) _ <br /> PHASE I - OR DEPARTMENT USE ONLY <br /> � <br /> APPLICATION ACCEPTED BY �. DATE _7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY --- DATE <br /> E H 1426 Rev. - I-74 6,177 �`� <br />