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�; SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> jEx'OFF E USE: r' 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No: 7,6,,1 /4J <br /> ?6_e p <br /> 4 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 9f the San Joaqpin Local Health District. <br /> Gf A/R�P�f? /FST �iN Rol <br /> JOB ADDRESS/LOCATION �J 1 CENSUS TRACT <br /> Owner's Name Phone <br /> Address I U�� % G � �'azl °� City ?7'1 <br /> Contractor's Name ,1 License # �' 3 Phone 'S <br /> 2a d4,4L <br /> ' 9 <br /> TYPE OF WORK (Check): NEW WELL. / DEEPEN •/? RECONDITION %l DESTRUCTION /7 }, <br /> PUMP INSTALLATION L� PUMP REPAIR/� PUMP REPLACEMENT <br /> Other /� <br /> DISTANCE TO NEAREST: SEPTIC TANK 10 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 /> X Domestic/private Drilled Dia. of Well Casing \ <br /> Domestic/public Driven Gauge of Casing X11 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout l 'T <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor �� <br /> Type of Pump �, H.P. <br /> PUMP REPLACEMENT: Lj State Work Done <br /> PUMP,REPAIR: <br /> / / 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 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 BY DATE - - � <br /> ADDITIONAL COMMENTS: <br /> PRASE II GR INSPECTION V PHAUIII INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ATE <br /> E H 1426 Rev. 1-74 _ <br /> 2M <br />