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SAN JOAQUIN LOCAL HEALTH DISTRICT AS <br /> . FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. U <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 <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. ll <br /> JOB ADDRESS/LOCATION / `��� � ,��E�/1 CENSUS TRACT <br /> I <br /> Owner's, Name Phone ? <br /> Address C7 �a_ ,�?t` .(� .._w,/C City <br /> Contractor's Name NEf20 License #2 Phone �. <br /> F TYPE OF,r_WORK (Check.) :_NEW_WELL-/F_/;.DEEPEN_ ./ - :./ <br /> _/ RECONDITION. / -DESTRUCTION-_// <br /> PUMP INSTA LATION / / PUMP REPAIR '/—/ PUMP REPLACEMENT /7 <br /> I Other / / <br /> DISTANCE TO NEAREST: ' SEPTIC TANK SEWER LINES '-� PIT PRIVY -- t <br /> SEWAGE DISPOSAL FIELD --- CESSPOOL/SEEPAGE PIT f- OTHER -- <br /> PROPERTY LINFt��PRIVATE DOMESTIC WELD fPUSLIC DOMESTIC WELL <br /> INTENDED USE A� 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 ;_ fGravel Pack Depth of' Grout Seal <br /> Cathodic Protection �_ Rotary Type of Grout <br /> Disposal 1 Other Other Information <br /> Geophysical ..._,...�.' ` Surface Seal Installed By: <br /> PUMP'INSTALLATION:_ _ _Contractor _ <br /> Type of Pump H.P. J <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP -.REPAIR;_ / / State :Work Done._. . . .._ a <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 wellin use. The above <br /> information is true t the b m k wledge and belief. I WILL CALL FOR A GROUT INSPECTION- <br />'PRIOR TO U AN A FINA I E i <br />: SIGNED TITLE ! r <br /> ( RAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I . , ' _,�' <br /> APPLICATION ACCEPTED BY � -- _ DAT '7� <br /> ADDITIONAL COMMENTS: -; <br /> - - -PHAS I GROU INSPECT--ION - - - - -= -PHASE /-FIN INSPECTION..- <br /> INSPECTION BY DATE ` .. 1` INSPECTION BY E ot j -_7_ <br /> � 1f77 <br /> E H 1426 Rev. Gs� r T -- f C62M- J <br /> 1-741 , <br />