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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 0—R70FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 J <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No�.f / /��� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued "7 <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 �� CENSUS TRACT <br /> Owner's NameAC <br /> Phone <br /> Address f l City . <br /> Contractor's Name ZZ,11A, <br /> License # Z6Dk�Phone <br /> TYPE OF WORK (Check): NEW WELL/? DEEPEN ,/-7 RECONDITION /7 DESTRUCTION F7 <br /> PUMP INSTALLATION _E1 PUMP REPAIR/_7 PUMP REPLACEMENT 17 <br /> Other /_7 — <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 Gravel Pack Depth of Grout Seal <br /> Cathodic Pxotect__ion Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By; <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump f H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: /7 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 /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 77 <br /> APPLICATION ACCEPTED BY 4, DATE ` <br /> ADDITIONAL COMMENTS; <br /> PHASE II GROUT INSPECTION P E AZZ/FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DAT <br /> E H 1426 Rev. 1-74 h/75 2M <br />