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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOk OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> r~ THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued// <br /> (Complete In Triplicate) <br /> Application is he a 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 apd the Rules arid Regulations of the San Joaquin Local Health District. <br /> AV/ z <br /> JOB ADDRESS/LOCATION / �N �TRACT <br /> Owner's Name 4ze JAN &LC Phone <br /> Address f[' / S � ��� City Ec c410tiC <br /> Contractor's Name License 4��; fL Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION/—/'-'PUMP REPAIR/ / PUMP REPLACEMENT /- <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK .Z SEWER LINES .-- PIT PRIVY �- <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINWOOPRIVATE DOMESTIC WELL E_1 PUBLIC DOMESTIC WELL _ - <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation /j9 " <br /> Domestic/private Drilled Dia. of Well Casing V <br /> Domestic/public Driven Gauge of Casing SF 4 <br /> Irrigation Gravel Pack Depth of Grout Seal GO <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor JVV. <br /> Type of Pump H.P. d <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 /> Wand 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 not'fy them before putting the well in use. The above <br /> information is true to the st Xmy wledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR T O I G A FIN I E <br /> SIGNED TITLE 4 a m7 <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 I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ATE <br /> E H 1426 Rev. 1-74 <br /> 1 IN 2M. <br />