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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS.OFFICE USE: ) 1601 E. Hazelton Ave. , Stockton, Calif. <br /> b Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �S <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 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 ' . CENSUS TRACT <br /> Owner's Name t�icPhone ` <br /> Address - <br /> Z,I7 �'-�-1 i. r City i eLe llt: <br /> Contractor's Name G License # U,/'i Z Phone - <br /> TYPE OF WORK (Check): NEW WELL DEEPEN/- RECONDITION /_7 DESTRUCTION f <br /> PUMP INSTALLATION/ / PUMP REPAIR/-7PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ..,.Q <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER (> <br /> ES <br /> PROPERTY LINE - PRIVATE DOMTIC WELL PUBLIC DOMESTIC WELL • Jt� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation h� <br /> Domestic/private Drilled Dia, of Well Casing �� Ch <br /> Domestic/public Driven Gauge of Casing f <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 Bv: ,f leiz" <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: /7 State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> ,m 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 INSPECTION <br /> ,> <br /> PRIOR TO GROUTING AND A FINAL ECTION. <br /> SIGNED .-­-'--.-,, TITLE �. y <br /> (DRAW-PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE --� <br /> ADDITIONAL COMMENTS: << <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE Z,,3! -;k� <br /> E H 1426 Rev. 1-74 4175 2M <br />