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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF' OFFICE USE: '1601 E. Hazelton Ave. , Stockton, Calif. <br /> - Telephone: (209) 466-6781 <br /> APPLICATION FOR'WELL CONSTRUCTION OR PUMP PERMIT Permit No. f! <br /> t E THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ��� <br /> r_c�.•,(Complete In Triplicate) a�$-Z�®---,� <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> _and./-cir install the work herein described. This application is made in compliance with San Joaquin <br /> CountyyOOrdi�nannce No.,�1862 and the Rules anti Regu1 t,'o of e a oaquin Local Health District. <br /> JOB ADDRESS OCA ION � <br /> ENSUS TRACT <br /> Owner's Name f _ Phone, ` <br /> Address 00f �► / <br /> City - <br /> Contractor's Name • ,�' ` <br /> s <br /> icensel/[ Phongl�/� <br /> TYPE OF WORK (Check) : NEW WELL /DEEPEN / / RECONDIION / / DESTRUCTION /_7' _ "t <br /> PUMP INSTALLATION A�::f' PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK ��/ SEWER LINES PIT PRIVY - - /�' <br /> SEWAGE DISP05AL FIELD CF,SSPOOL/SEEPAGE PIT OTHER _ <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL • � PUBLIC DOrLESTLC WELL <br />` INTENDED USE TYPE OF WELL - {� <br /> ,.., ,;,, CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> L�$omestic/private Drilled Dia, of Well Casing Z <br /> Domestic/public Driven Gauge of Casing J. <br /> Irrigation <br /> 1 Gravel Pack Depth of Grout Seal <br /> Cathodic Protection i Mary Type„of Grout <br /> Disposal ._,. ! Other Othei Information ' <br /> Geophysical" � Surface Seal Installed By: ' I <br /> PUMP INSTALLATION;,, ;-Contractor � � <br /> Type of Pump <br /> PUMP REPLACEMENT: State <br /> Work Done <br /> PUMP REPAIR: State"Work Done <br /> 4 <br /> DES-TRUCTION OF WELL: Well Diameter. ' <br /> ' Approximate Depth <br /> Describe Material and Procedure " <br /> I hereby agree to comply with.kall laws and regulations of the San Joaquin Local Health District y <br /> and the State of California pertafing to or regulating well construction. Within FIFTEEN DAYS-- <br /> after completion of my wor--k-oma 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 CROU N.G DfA FINAL�INSPECTION_, <br /> SIGNED <br /> TITLE <br /> (D W PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 01"a <br /> APPLICATION ACCETED BY <br /> ADDITIONAL COMMENTS:R._ �, _ DATE 12 2- <br /> PRASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION'-BY -” '- -- -DATE - ;�Z t "�_„ ,` "gINSPH-CTLON ABY � � DATE <br /> ' -� .. , <br /> E H 1426 Rev. • 1-74 _ 2M <br />