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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 ^ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z -y <br /> c�11 THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date- Issued <br /> k-i <br /> ' kms" (Complete In Triplicate) <br /> Application Gj— <br /> is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein describe This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rul and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phon <br /> / � <br /> Address wjj Ci _ <br /> Contractor's Name Licenselj�Z P h o n <br /> TYPE OF WORK (Check): NEW WELL/_ DEEPEN / / RECONDITION / / DESTRUCTION /_ <br /> PUMP INSTALLATION/—/ PUMP REPAIR/ / 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 <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 <br /> Irrigation `Q' avel 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. 0 <br /> YV- <br /> PUNP REPLACEMENT State Work Done <br /> PUMP .REPAIR: / / 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 /> D W PLAN 'ONTSE SIDE) <br /> ME ,. <br /> R DEPARTtENT USE ONLY - <br /> PHASE I <br /> APPLICATION ACCE v EL DATE AI::;,. <br /> ADDITIONAL COMMENTS: <br /> PHASE GROUT INSPECTIONPHASE INAL INSPECTION <br /> INSPECTION BY _ DATE _._ INSPECTION BY _ TE G)_ ; <br /> 41 <br /> T <br /> E H 1426 Rev. 1-74 3/76 2W <br />