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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton,Avd a, 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 /> a 4-ordinance <br /> install the work herein descr'bed. This ap lication is made in compliance with San Joaquin <br /> No. 1862 and the Rd a`tfI ns of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Q OF WBT 46&jE DF S_P TJ�'i9 CENSUS TRACT <br /> Owner's Name - ARt A 0 �� � -�f Lr � Phone 3(o!?-- 44-5- <br /> Address 9!2.6 49 -Ad" �AIE City <br /> Contractor's Name License # Phone ? "3-:r" <br /> D Box •e- <br /> TYPE OF WORK (Check) : NEW WELL /Y DEEPEN / / RECONDITION / / DESTRUCTION /- _ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK -7,00 ,,' SEWER LINES QQf PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE/&APRIVATE 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 �(l <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 the well in use. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTIQN <br /> PRIOR TO GRO ING AND A FINAL S CTION. ��- <br /> SIGNED y TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR D PARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE %--' <br /> /)/ <br /> ADD� IONAL COMMENTS. <br /> PHASE II GROUT INSPECTION; PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. - I-74 °'�77 _ 2M <br />