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SAN JOAQUIN LOCAL HEALTH DISTRICT / <br /> FOP OFFICE USE: 1601 E. Hazelton Ave. , 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 ��3 <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 JoeQv <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District <br /> JOB ADDRESS/LOCATION <br /> 6;,�a x>xt" CENSUS TRACT <br /> Owner's Name 14 a Phone <br /> Address S CY O w S _T_/:) City �o <br /> Contractor's Name License # 7y4�Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN %% RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /_ <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 SPECIFICATIONS u <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <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 a <br /> H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP '. ; <br /> . �C/ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> 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 wellconstruction. 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 k 9wled and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO I G AND A FINAL IN I <br /> SIGNED <br /> (D W T P AN ON REV E SIDE) j <br /> PHASE I OR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY �- DATE ,-2 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P /FINAL INSPECTION <br /> INSPECTION BY - DATE INSPECTION BY DATE <br /> E H 1426 Rev. -74 1127 <br />