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SAN JOAQUIN �LOCAL HEALTH DISTRICT <br /> FOH.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> r, 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 6�_ <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 CENSUS TRACT <br /> Owner's Name ' Nly H, )1WK11yg Phone <br /> Address City <br /> Contractor's Name ; 0 S,C fu License #Q2 7Phone RE <br /> • <br /> TYPE OF WORK j6heck.) NEW WELL, / / DEEPEN /_/ RECONDITION / / DESTRUCTION /_7 ' <br /> PUMP INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST:--„ SEPTIC TANK SEWER' LINES .. PIT PRIVY <br /> 4­'' SEWAGE DISPOSAL FIELD j CESSPOOL/SPEPAGE-P:IT OTHER <br /> PROPERTY LINE - PRIVATE DOIAESTIC WELL ”- PUBLIC-DOMESTIC WELL �. <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> `Indids triaP:i ='' Cable Tool Dia. of Well Excavation <br /> yDo'_me ,tic/private Drilled F Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation' '`' ' ' Gravel Pack Depth of Grout Seal <br /> N <br /> Cathodic•,Protec.iion, Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed .B : <br /> PUMP INSTALLATION: Contractor . : <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: <br /> . / / State Work Done -�- _ __ <br /> 777, <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 thewell in use.. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GROUT;.VG AND A FIW INSPECTION. <br /> SIGNED ) TITLElf`,d <br /> (DRAW .PLOT PLAN ON REVERSE SIDE) 1, <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY r� DATE S 7? <br /> ADDITIONAL COMMENTS: <br /> PHASE TI.,GROUT INSPECTION PHASFV II7„I INAL INSPECTION,r� <br /> INSPECTION BY DATE INSPECTION BY ' DATE <br /> , 1777 _ 2M <br /> E H 1426 Rev. 1-74 . <br />