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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Ofi 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 <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 /> l <br /> JOB ADDRESS/LOCATION t44 , 4:2 �' CENSUS TRACT <br /> Owner's Name -21 Z 39-Z�4 Z <br />�4 <br /> Address City <br /> Contractor's Name icense � Phone?� 3 <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN /_/ RECONDITION /_/ DESTRUCTION /7 _ <br /> PUMP INSTALLATION I I PUMP REPAIR / / PUMP REPLACEMENT I I <br /> I <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK ay SEWER LINES PTT PRIVY - <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> f PROPERTY LINE - PRIVATE DOMESTIC WE' LL .— PUBLIC DOMESTIC WELI <br /> „f° INTENDED USE . . -. - TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br />-___;Industrial _ Cable Tool, Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing. �j <br /> GN <br /> Domestic/public Driven Gauge of Casing ! ' <br /> Irrigation Gravel Pack Depth of Grout Seal f <br /> Cathodic Protection otary Type of Grout le <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 Donek <br /> PUMP .REPAIR: /-7/ State Work Done <br /> DESjRUCTION,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 j <br /> information, i.s 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 ' <br /> . 1 <br /> APPLICATION ACCEPTED BYZ9 DATE <br /> ADDITIONAL COMMENTS: 17 <br /> PHASE II GROUT INS ECTION PHAS II/ IN PECTION <br /> INSPECTION BY DATE INSPECTION BY 7 <br /> q� <br /> E ,H 1426 Rev. - I-74 <br /> �DQ� # <br />