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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOSfOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> A Telephones: (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 ';E CENSUS TRACT <br /> Owner's Name �lS Phone , <br /> Address ' , ' z1z: City ./-- G// 1 <br /> Contractor's Name _.1 a 1 PG G _ License # 244,0 2 Phone VK.V-.5-6-W <br /> TYPE OF WORK (Check): NEW WELL/_7 DEEPEN /7 RECONDITION /27 DESTRUCTION <br /> PUMP INSTALLATION %/ PUMP REPAIR /7 PUMP REPLACEMENT <br /> Other <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 v j <br /> ' Domestic/private Drilled m Dia. of Weil Casing <br /> Domestic/public Driven Gauge`of Casing <br /> k' 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: Ll State Work Done 1 <br /> PUMP.:REPAIR: /7 State Work Done 1 <br /> ES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and-Procedure <br /> 6 F <br /> M <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 TOG- TING. AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> f DRAW PLOT PLAN ON REVERSE SID ' <br /> FOR DEPARTMENT- USE ONLY-- <br /> PHASE <br /> NLY-PHASE I <br /> APPLICATION ACCEPTED BY DATE f 2- 7 17-51 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INVECTION PHASE III FTNAL INSPECTION <br /> INSPECTION BY DATE INSPECTION $Y DATE r l� <br /> E H 1426 Rev. 1-74 -74 2M <br />