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SAN JOAQUIN LOCAL HEALTH DISTRICT 0- ' <br /> FOF OFFICE USE: 1601 E. Hazelton Ave'. , Stockton, Calif. 0% <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issuedo2/``-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 Jo4quin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION S C" ,� CENSUS TRACT <br /> Owner's Name Phone <br /> Address City fhMF 611 CA MR -- <br /> Contractor's Name C_�,Ol License # %GUZ Phone � -bar <br /> i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY t <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 _ /2 <br /> Domestic/private # Drilled Dia:7of Well Casing 12 <br /> Domestic/public Driven ''Gauge of Casing /ST <br /> Irrigation ._ A Gravel Pack Depth of "Grout Seal <br /> Cathodic Protection Rotary Type of Groht <br /> Disposal Other Other Information <br /> Geophysical _ Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractgr �T ^ <br /> Type of ;pump H.P. <br /> 's <br /> PUMP REPLACEMENT: / / S talte Work Done <br /> PUMP .REPAIR: / / Sta"e 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 est;of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR TIN D A FI INSPECTION. ` <br /> SIGNED - TITLE _40WAJ9 <br /> :/V <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 000f <br /> _ <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: Cv yL71.ZT <br /> PHASE II GROUT I ECT ON PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> r y <br /> E H 1426 Rev. 1-74 1177 2M <br />