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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOk OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone; (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> - ,--r <br /> , (Complete In Triplicate) <br /> Application is tereby 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 Jgaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local. Health District, <br /> JOB ADDRESS/LOCATION 40 CENSUS TRACT <br /> Owner's Name 13 Phone <br /> Fao TI�I�, wT Iii - <br /> Address City <br /> Contractor's Name -� ��e� License # jL_7j` Phone <br /> TYPE OF WORK (Check) : NEW WELL /% DEEPEN -/—/ RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION / PUMP REPAIR /% PUMP REPLACEMENT /7 <br /> Other /_7 to <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 <br /> Domestic/private Drilled Dia. of Well Casing <br /> _ Domestic/public Driven Gauge of Casing <br /> 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 (L4 H.P. <br /> PUMP REPLACEM$NT / / State Work Done <br /> PUMP .REPAIR: /_7 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 bistti6t , <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.y,� <br /> SIGNED �� .G �, ;,cc TITLE <br /> ®(DRAW PLOT PLAN ON REVERSE SIDE) <br /> 6 FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYDATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA5 I I FIML INSPECTI N <br /> INSPECTION BY DATE INSPECTION BX DATE <br /> E H 1426 Rev. 1-74 lf_77 <br />