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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOB OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif, u <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � •Z <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued J�o? <br /> (Complete In Triplicate) <br /> Application is Aereby 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 he Rules an Re at ns of the San Joaquin Local Heath District. <br /> ��Z�:%�v <br /> JOB ADDRESS/LOCA T N 71 <br /> CENSUS TRACT <br /> Owner's Name Phone � ` <br /> Address ✓ City ' <br /> Contractor's Name License es 3/13b one <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /_% RECONDITION /-7 DESTRUCTION /-7PUMP INSTALLATION / UMP REPAIR ./O— LACEMENT /-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 SPECIFICATION <br /> _ Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public — Driven Gauge of Casing IN <br /> Irrigation Gravel Pack Depth of Grout Seal Q <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: <br /> State Work ontz <br /> DES•®RUCTION 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 bistrict <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 /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED R Q� . ,, �. TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> .�l� <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE g'2-� '7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE, IIIIFINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY „- DATE <br /> E H 1426 Rev. 1-74 <br /> 1177. ` 2H <br />