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SAN JOAQUIN LOCAL HEALTH DISTRICT C <br /> FO1Re'OFFICE USE: 1601 E. Hazelton Ave, , Stockton, Calif. U Y <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. lZp}o <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 Regul ons of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Phones <br /> Address <br /> Contractor's Name _ _ err✓ r ,, � License!# ' -� --� PhoniW'f"- <br /> TY /_7 <br /> _ -. <br /> PE OF WORK (Check): NEW WELL /7 DEEPEN '/-7 RECONDITION /� DESTRUCTION /J� <br /> PUMP INSTALLATION /_. / PUMP REPAIR / / PUMP REPLACEMENT <br /> ©Cher /_7 w <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER w 1 <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 l� <br /> Domestic/private Drilled t Di-a.-,of-Well 'Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout SealI` <br /> Cathodic Protection Rotary Type of Grout Mj <br /> 'Disposal H Other Other Information <br /> Geophysical ,. Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor ' <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ] / State Work Don ; <br /> PUMP .REP,AIR <br />.. J . State Work Done <br /> _. <br /> &ES-TRUCT;ION 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 SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED 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 -74 2M <br />