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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OF°7ICE USE: 4..ivt� 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> % r � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date 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 `>- �� j� Mi" �CC�1� NSUS TRACT <br /> Owner's Name EAV Phone9691/„Je?j <br /> Address �D J7� 1l5/�/9 -S j; City <br /> Contractor's Name � � �: /L 1 License 11-53YZ-Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_/ RECONDITION /'—/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT G <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK X—eff SEWER LINES PIT PRIVY _ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINEVPRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL � <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial yCable 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 H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> - -Describe Material end Procedure - - <br /> I hereby agree to comply with all laws and regulations of the Safi*'Joaquin Local Health District <br /> and the State of California pertaining to or regulating well 'conotruction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish 'the Sean 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 GROUWTNG AND FI%,u P TION. <br /> SIGNED TITLE <br /> r (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 INSPECT 0 PHASE III/FINAL INSPECT 0 <br /> INSPECTION BY DATE INSPECTION BY DATE [ <br /> E H 1426 Rev. , 1-74 0/77 _ 2M <br />