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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FBF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466--6781 i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.J0 I <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 theRulesand Regulations <br /> of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION -' -�t -� /` - < < i- CEN S TRACT <br /> Owner's Name %�/ - � (. s.',,r � ht - << Cfc�� '�Phone <br /> Address ^= -- city <br /> ems"' . t s.�":;�� j�� �� -��y License 4fc <br /> Contractor s Name .. "- Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /_/ RECONDITION /_/ 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 <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 X <br /> Disposal Other Other Information t, <br /> Geophysical Surface Seal Installed By: Ct, <br /> t,. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. _. <br /> PUMP REPLACEMENT: / State Work <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter _ Approximate Depth <br /> --- <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 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 GR UTING AN INAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 12 i "" 77 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASEeIJOI/FINAL INSPECTI0 <br /> INSPECTION BY DATE INSPECTION BY DATE 177 <br /> n,/-r7 <br /> E H 1426 Rev. - I-74 <br /> _ <br />