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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOk*OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 4666781 <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 Nor 1862 and AF/ etules and Regulations of the San Joaquin Local Health D*st1rict. <br /> JOB ADDRESS/LOCATIONJOB ADDRESS/LOCATION, 2 ,;4 Cu. CENSUS TRACT <br /> Owner's Name Phone �' V3 <br /> n 9 <br /> Address / '7 / � � City ', <br /> Contractor's Name �V,e�-��-'� pv -r— License4��L ?� Phone3C <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /-7 RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY 1 <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: 7 State Work Done <br /> PUMP '.REPAIR: /-7 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 Healt istrict <br /> and the State of California pertaining to or regulating well "construction. Within FIFTEEN DAY: <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 rue to the best of my knowledge and belief. I WILL CALL FOR A GROAT INSPECTION <br /> PRIOR TO GROU G D A INSPECkION. <br /> SIGNED TITLE <br /> 2<CDRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �/° <br /> APPLICATION ACCEPTED BY dL ✓s�G DATE G%Z©_-2 ? <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL MPEdTI614 <br /> INSPECTION BY DATE INSPECTION BY f '" DATE <br /> E H 1426 Rev. 1-74 1177 2M <br />