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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOA;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif.. <br /> Telephone (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 'EL-s33 4/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDDate 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 No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION "� � U 611-'10e' L/ Z4 � CENSUS TRACT <br /> Owner P s NamePhone '?l7 "�? <br /> Address <br /> City <br /> Contractor's Name , <br /> License -43F"Phone �,t�A1<i',9y <br /> TYPE OF WORK (Check): NEW WELL/ DEEPEN 1-7 RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTALLATION // PUMP REPAIR /-7 PUMP REPLACEMENT /7 <br /> Other /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PI-T-/-tff 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 �1 <br /> Domestic/public Driven Gauge of Casing2 r Jk <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection 4I Rotary Type of Grout 's <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor ell <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: /7 State Work Done <br /> ES•TRUCTION 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 thewell in use.. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GR UT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE41* <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> P II G UT IN PECTIO PHAS III NAL INSPECTIO <br /> INSPECTION B ATE G INSPECTIONBY ATE <br /> ,� E H 1426 Rev. 1-74 -74ZM <br />