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f � SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE;OCFICE 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 / -7 <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 Lo pl Health District. <br /> �6 90 mow.. ,d��„ <br /> JOB ADDRESS/LOCATION '"' � eo`', ►.�• se 4 t first • CENSUS TRACT <br /> Owner's Name /6 it- / Y ..d' Phone <br /> Address City �Cc, 1► <br /> V <br /> Contractor's Name License #/'&7A''Thone 750 <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN /7 RECONDITION %f DESTRUCTION %f <br /> PUMP INSTALLATION I / PUMP REPAIR /77 PUMP REPLACEMENT /7 <br /> Other % <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER \R <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 /> �r <br /> PUMP INSTALLATION: Contractor <br /> Juooze- <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: j/ / State Work Done <br /> PUMP ,REPAIR: 7 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.knowl ge belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPE <br /> SIGNED ITLE <br /> RAW PLOT LAN ON R RSE SIDE <br /> FOR 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 4 2M <br />