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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 0%V CE USE: '` 1601 E. Hazelton Ave. , Stockton, Calif. <br /> F Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;W,a jo Ao <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 zf�- 'A, R/ . r \ ; r ' � CENSUS TRACT <br /> r <br /> Owner's Name - -r n . , ,6 �. t._. Phone <br /> Address City d , <br /> Contractor's Name S e ' ";D License # Phone Z '76 <br /> 17 <br /> TYPE OF WORK (Check): NEW WELL/? DEEPEN '/7 RECONDITION j7 DESTRUCTION /7 <br /> PUMP INSTALLATION/—/ PUMP REPAIR-j-C� PUMP REPLACEMENT 17 <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 <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 j <br /> Disposal _ Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump - e. H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> c <br /> PUMP REPAIR: State Work Done cc c � <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 /> 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..weli. in.use.... The above <br /> information is true to the•best.of .my,know dge aii belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO ; U ING AIJD A FINAL I CTIO <br /> SIGNED `G ITLE <br /> A, LO PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COHMENTS: <br /> PHASE II GROUT INSPECTION PHASE ljZ INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 h/79 2M.v__ <br />