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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFx;OFFICE USE: 1601 E. Hazelton Ave. '' Stockton, Calif. <br /> 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 1( . <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 ,q-490. ejV 4 <br /> yfo�d/ CENSUS TRACT <br /> Owner's Name p ,� Phone <br /> { <br /> Address City . 2'R,4C <br /> Contractor's Name . h f ,. License # r�Phone 52,;22452 <br /> TYPEOFWORKI(Check): NEW WELL RECONDITION/_7 DESTRUCTIONy/_ <br /> PUMP 'INSTALLATION / / 7PUMP REPAIR '/� PUMP REPLACEMENT /f <br /> Other / <br /> DISTANCE-TO NEAREST: SEPTIC TANK SEWER LINES AV 7, PIT PRIVY <br /> SEWAGE DISPOSIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY' LINEAL RIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED. USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ' , Cable Tool Dia. of Well Excavation Awl, <br /> Domestic%private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing % <br /> Irrigation- Gravel Pack Depth of Grout Seal- - <br /> Ca thodi c, <br /> ealCathodic,Protec_ti_ on —k—Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed 'B : <br /> PUMP INSTALLATION: Contractor <br /> Type .of Pump H.P. <br /> PUMP REPLACEMENT:: / / State Work DoneW <br /> F'UMP .REPAIR: /� State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> µ 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 , tr to the-best-of- my- knowledge and belief.. I WILL CALL FOR A -GROUT INSPECTION <br /> PRIOR TO x D A . N. <br /> SIGNED - ' <br /> TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I: <br /> APPLICATION ACCEPTED BY00fDATE '" --� <br />.ADDITIONAL COMMENTS: <br /> PHASE II OUT INSPECTION PHAUIII AL INSPECTION <br /> ON <br /> INSPECTION BY DATE -- ., INSPECTIBY DATE r,,j;' <br /> E H 1426 Rev. 1-74 h/75 2M <br />