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(� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: j� T1601 E. Hazelton Ave. , Stockton, Calif. <br /> � 4 L 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 1�_7 <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 T2 .Q� Phone 2,5 _ <br /> 'j - <br /> Address City _ <br /> Contractor's Name Cpj" D,& cp, License /N/ Phonaij-6I3 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN %/ RECONDITION j�/ DESTRUCTION /7 <br /> PUMP INSTALLATION / PUMP REPAIR j / PUMP REPLACEMENT <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 M <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIQNS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> omestic/private _u,VDrilled 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: 4'7.yir/ <br /> PUMP INSTALLATION: Contractor _ <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> a � <br /> PUMP / / State Work Done <br /> -- oz"q 70 6 ,ad G ;4i+-ivG&,oV �yr. A1/� <br /> : 4 <br /> ES-TRUCTION OF WELLell Diameter <br /> �, T _yd.✓j�J iprd�' �'S5 p '- <br /> ✓ / <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 ANDA INAL INSPECTION. <br /> SIGNED TITLE _ <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ' / <br /> ADDITIONAL COMMENTS: <br /> PHASE,ay GROUT INSPECTION PHA II/ NAL INSPECTION <br /> INSPECTION BY DATE _, j INSPECTION BY DATE78 <br /> E H 1426 Rev. 1 ` <br />