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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE76F-FILE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 _ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> j THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application hereby made to the San Joaquin Local Health District foraermit to construct <br /> p <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 ,2t e San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �s « CENSUS TRACT <br /> Owner's Name �A'3 <br /> � Phone <br /> Address City . d7'j'�d <br /> Contractor's Name License #62?&&j Phone -V2- OSI <br /> TYPE OF WORK (Check): NEW WELL, / DEEPEN /-7 RECONDITION /-7 DESTRUCTION /—J v <br /> PUMP INSTt�LLATION / / PUMP REPAIR-/-7—pump REPLACEMENT 17 <br /> Other /-7 <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�STIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br />___,t..- Domestic/private ,&::,-Drilled Dia. of Well Casing e S' <br /> Domestic/public Driven Gauge of Casing Z.:2- <br /> Irrigation <br /> ,zIrrigation 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 A.P. <br /> PUMP REPIACEMEM . / / State Work Done <br /> PUMP .REPAIR: /-7 State Work Done <br /> LEES,•TRUCTION 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,bes t of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G OUTINGAND INSP IO . , <br /> DRAW T ON REVER SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I \� <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL,COMMENTS: <br /> PHASE II GROUT INSPECTION PHASEI INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE O_ <br /> E H 1426 Rev. 1-74h/75 2M <br />