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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> J Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �S- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7S� <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 L7670 CENSUS TRACT <br /> Owner's Name Phone <br /> Address CQ City <br /> Contractor's Nasse � .� � � � License.# �Q Phone <br /> TYPE OF WORK (Check): NEW WELL - ,IRT DEEPEN '/-7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INST LATION / / PUMP REPAIR/=7 PUMP REPLACEMENT /7 <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 v <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 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 H.P. <br /> PUMP REPLACEMENT /_7 State Work Done,_ <br /> PUMP 'REPAIR: /% State Work Done -.-.—� <br /> DES-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-best-of my-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUT Gr; F A FINAL INSPECTION. <br /> SIGNED TITLE ..rr�?.lc. <br /> DRAW PLOT PLAN ON REVERSE SID <br /> PHASE I — <br /> FOR DEPARTMENT USE ONLY <br /> , <br /> APPLICATION ACCEPTED " DATE , <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P III FINAL INSPECT ON <br /> INSPECTION BY DATE L 3o f INSPECTION BY DATE <br />�� E`H 1426 Rev. 1-74 h/75 2M _ <br />