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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: Lir', 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 /�`d �� 1 �/ CENSUS TRACT <br /> Owner's Name ,o,ti,,,J 4 <br /> � Phone �Ws-/6sz <br /> Address �� 6,2, t-1 /c cs City <br /> Contractor's Name License # ,,�3,X) Phone d 964?S <br /> i <br /> TYPE OF WORK (Check) : NEW WELL /-7 DEEPEN '/ / RECONDITION Fl DESTRUCTION /-7 <br /> PUMP INSTALLATION/ / PUMP REPAIR /--/--pump REPLACEMENT /7 <br /> Other / / <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 DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL 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 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 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 thewellin 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 G OUTING AND A FINAL INSPECTION. <br /> SIGNED Kdpj, TITLE <br /> D W PLAN ON RE kSE SIDE <br /> DEP T USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPT47.,'R <br /> Sc IV!f E DATE - 93 <br /> ADDITIONAL +COMMENTS: <br /> PHASE II : ROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BYDATE INSPECTION BY DATE '11?� <br /> r <br /> H 1426 Bev. 1-74 <br /> � 6 2K <br />