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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOR OFFICE USE: ' 1601 E. Hazelton Ave. , .Stockton, Calif. <br /> Telephone: (209) 466-6781 /�-f <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 'd '0 � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7 Y <br /> (Complete In Triplicate) <br /> Application is Aereby 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 ��S d �-e�' C� CENSUS TRACT <br /> Owner's Name Phone y�, <br /> Address � � �' zd City -// 4 <br /> Contractor's Name G /,,/3 9 <br /> License "(iZ. PhoneF <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTAL TION / / P REP.QIR / UMP REPLAC N / <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/privateDrilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing T <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 H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter ' -41/ ' Approximate Depth <br /> Describe Material nd 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 FINAL INSPECTION. <br /> SIGNED VTITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE.E47-7,9 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPEtTION PHASE'.'I:LI/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 1177 <br />