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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR•t 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 01 t fl $ A LtS yC- i^r11 �04 CENSUS TRACT <br /> Owner°s Name /4 .S• /� u n ,� Phone <br /> Address City <br /> Contractor's Name - w <br /> License # /�,�'�,�t Phone S/ �Z�L <br /> TYPE OF WORK (Check): NEW WELL L7 DEEPEN /7 RECONDITION /7 DESTRUCTION L7 <br /> O herl /�NSTALLATION L-7—PUMP REPAIR PUMP REPLACEMENT 17 <br /> 41 <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 /> _ X 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: L7 State Work Done <br /> PUMP :REPAIR: fg State Work Done ,,.• d fir .� ��� <br /> ,SES-TRUCTION 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 ledg a be f. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO TING AND A FINAL INSPECTI <br /> SIGNED <br /> E <br /> gDRAX P P ON REVE SIDE <br /> DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 1-74 2M <br />