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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOBS OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <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 an 6t}e R Vesandulations of. the San Joaquin Local Health District. <br /> yo <br /> JOB ADDRESS/LOCATION ! CENSUS TRACT <br /> Owner's Name AA Phone <br /> Address <br /> _ �1 g.f" Al , 1*e Q./rr�a r_-)0-ye tY City <br /> Contractor's Name cti) License , Phone <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN /7 RECONDITION /- DESTRUCTION /7 <br /> PUMP INSTALLATION /� PUMP REPAIR &-7—PUMP REPLACEMENT f <br /> Other /7 <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 � . <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor 4tv e) <br /> Type of Pump H.P. e,40 <br /> PUMP REPLACEMENT: /7 State Work Done <br /> PUMP :REPAIR: /17 State Work Done34,re <br /> D S,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 knowledge a belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G OUTING AND A FINAL I <br /> SIGNED TLE <br /> D W T LAN ON REIERSE SIDE <br /> DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE If GROUT INSPECTION S FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION <br /> 7 7— <br /> E H 1426 Rev. 1-74 1-74 2M <br />