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lSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> -FO-F-OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> I Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 /> iCounty Ordinance No. 1862 an' the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CU, Vr CENSUS TRACT <br /> Owner's Name i / .�` ,Q ,"411 Phone �2�1- <br /> Address t� ._ City <br /> E k <br /> Contractor's Name F. License Phone z a�/ �i <br /> 112. <br /> TYPE OF WORK (Check) : NEW'WELL / ./ DEEPEN / / RECONDITION / / ' DESTRUCTION /_ <br /> PUMP INSTALLATION -/�/ 'PUMP -REPAIR je�;, PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY I <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 t Drilled Dia. of Well, Casing.. <br /> Domestic/public 1 Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout. Seal ! <br /> Cathodic Protection { Rotary Type of Grout <br /> Disposal 1 Other : Other Information <br /> Geophysical 1 Surface Seal Installed By: <br /> 4. - <br /> UMP INSTALLATION: "Contractor <br /> P <br /> Type of Pump H.P. --- <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP -REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 1 t <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 rue to the best of my-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU G A INSPECTI <br /> SIGNED TITLE <br /> } D <br /> .:KOT PLAN ON REVERSE SIDE <br /> i <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> 1� <br /> APPLICATION ACCEPTED BY DATE - � <br /> ADDITIONAL COMMENTS: 1 <br /> PHASE II GROUT INSPECTION PHASE I VEINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY <br /> E H 1426 Rev. 1-74 376 2M <br />