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* SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FO'E OFFICE 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 <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 ' , Phone cS` <br /> Address /. 2 �-�• /�V City <br /> Contractor's Name .20 License Phone A& 6.3��793� <br /> i <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN / / RECONDITION / / DESTRUCTION <br /> PUMP INSTILLATION / / PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK _ 0 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 / <br /> k--Domestic/private L--15-rilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing G /60, <br /> Irrigation Gravel Pack Depth of Grout Seal —5--d <br /> Cathodic Protection , Rotary _ Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: T _ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <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 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 GR G AND A FI INSPECTION. <br /> SIGNED TITLE <br /> :,�(DRAkWgLOT PLAN ON RE EkSE SIDE)— <br /> FOR <br /> IDE) `FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATErf g <br /> ADDITIONAL COMMENTS: <br /> VPHAS II GR UT INSP TION PHAS III/FINAL INSPECTION <br /> INSPECTION BY DATE —b=2 INSPECTION BY DATE <br /> gf76 <br /> E H 1426 R v. J. <br />