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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOSrOFFICEUSE: '1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued I--/---Z,(-to cons <br /> (Complete In Triplicate) . <br /> Application is hereby made to the San Joaquin Local Health District for a permtruct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862�an� . hhe Ru sand Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 7&- tie CENSUS TRACT <br /> Owner's Name Phone <br /> Address <br /> City , f <br /> /� <br /> Contractor's Name � e��y _C9 eOC # <br /> _ License Phone <br /> TYPE OF WORK (Check): NEW WELL J-7 DEEPEN '/-7 RECONDITION /7 DESTRUCTION _ <br /> PUMP INSTALLATION / / PUMP REPAIR /� PUMP REPLACEMEN %f <br /> Other L/7 S <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 Gid! <br /> Domestic/private Drilled <br /> Dia. of Well Casing <br /> Domestic/public i Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal 7 <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> L�Geophysical - ---._. <br /> Surface Seal Iastalled BY: <br /> PUMP.INSTALLATION: i <br /> Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: <br /> j//- State Work Done <br /> UMP `.REPAIR: <br /> / / State Work Dane - <br /> # f <br /> ESTRUCTION OF WELL; Well Diameter <br /> Describe Material and Procedure Approximate Depth,, <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 worm on a new well, I will furnish the San Joaquin Local- Health 'District <br /> WELL DRILLERS REPORT of the well and motif them before <br /> Y putting.. the .well in .use'. The above E <br /> information is true to the best of my.knowledge and belief. I WILL GALL FOR -A 'GROUT-.-INSPECTION ► <br /> PRIOR TO GROUT G D A FIN 57INSPECTION. p <br /> gIGNED ; TITLE 19e Nl�t y + <br /> � . (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I <br /> PLIFOR DEPARTMENT USE ONLY <br /> �;� . <br /> APCATYON,ACCEPTED B DATE7� <br /> ADDITIONAL COMMENTS: ; <br /> s PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTIONBY DATE INSPECT ON BY DATE <br /> 7 <br /> 1- <br /> E H 1426 Rev. 1-74 fLP-7/, 7M <br />