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SAN JOAQUIN LOCAL HEALTH DISTRICT , <br /> FOA; FFICE 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 <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 goo .4 411-g 1w fln P. o ,rj n CENSUS TRACT <br /> Owner's Name ��,,. � y�e , ,�' , Phone <br /> Address C) Cit <br /> ,p <br /> y <br /> Contractor's Name License # /yJ 7 ►'Phone i, ?6.7 <br /> TYPE OF WORK (Check): NEW WELL/-7 DEEPEN /_� RECONDITION /-7 DESTRUCTION /-7 <br /> AL <br /> PUMP INSTLATION � PUMP REPAIR / / PUMP REPLACEMENT 17 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER (I1 <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS pb <br /> Industrial Cable Tool Dia. of Well Excavation r• <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 PumpH.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP-i1!RKgFr / State Work Done <br /> ,SES®RUCTION 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. well in use.. The above <br /> information is true to the best of Vpowr anfi elief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPEN. ,- -� <br /> SIGNED LE �riL1" a <br /> PLOT PLAN ON REV SE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE r <br /> ADDITIONAL COMMENTS <br /> PHASE II ROUT INSPECTION PHASE I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE yC� 16 7. <br /> ! E H 1426 Rev. 1-74 1-74 2M <br />