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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR 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 /> t (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 Rulessj and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION < �,, _.. '�c C '2 d-L L CENSUS TRACT <br /> Owner's Name ` -f` �, Phone <br /> City <br /> Address f C_ �S�:S— 7r' c.r_,(/i/� ti <br /> Z L �Z-� <br /> 11-7 <br /> Contractor's Name((� �G-c�ti'�c, �- License J{�ec<4 Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION_/ / DESTRUCTION /-7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUZH' REPLACEMENT /-7 <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 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing �1 <br /> Irrigation Gravel Pack Depth of Grout Seal CA <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: -c --.� ., <br /> PUMP INSTALLATION: Contractox-�;il.�Y <br /> Type of Pump <br /> H.P. <br /> c' <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material a d 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 D YS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health Distric <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 AON A FINAL INSPECTION. <br /> SIGNED . ' C TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I _ -7 <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT IlTSPECTION PHASE /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> b/77 <br /> E H 1426 Rev. • 1-74 <br /> _ 2� y <br />