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✓ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: • 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR: PUMP PERMIT Permit No. 7� 1t}�oZ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued6-Z$' <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 �,, ��4%VL_ CENSUS TRACT <br /> Owner's Name / /, I Phone <br /> Address Z � `r ,[�ljy_ _l3�1 ,L�, City <br /> U <br /> Contractor's Name License hone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION /_/ DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK Q SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT _ OTHER , <br /> PROPERTY LINE LO 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 <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: CTU22� <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> r <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <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 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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �A/ <br /> APPLICATION ACCEPTED BY Z/ DATE <br /> ADDITIONAL COMMENTS: <br /> PHAS /� GR0 T INSPECTI N PHASE /FIN INSPECTION <br /> INSPECTION BY L -y DATE 7tf INSPECTION B� DATE/ 7 <br /> E H 1426 Rev. � 1-74� <br />