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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: " 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 ri <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,Z-AY <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued17 <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 Joequin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> J08 ADDRESS/LOCATION J CENSUS TRACT I <br /> Owner's Name Phone . r / <br /> Address City . /Q/� <br /> f <br /> Contractor's Name _�, D v) License License �� Phone <br /> i <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 4 <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 1�\ <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing pp <br /> Irrigation Gravel Pack Depth of Grout Seal l� <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 /> r <br /> PUMP REPLACEMENT: X ;State Work DoneAJ Z <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth j <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 /> DRA PLAN ON REVERSE SIDE) <br /> DEPARTMENT USE ONLY <br /> PHASE IA- 3 <br /> APPLICATION ACCEPTED BY �j DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE 11 C CZ-,ON P SE /FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE r <br /> U Z7 2M <br /> E H 1426 Rev. 1-74 <br />