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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466,-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 21 1ph�aoO <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 andthe Rules and Regulations of the San Joaquin Local Health District. <br /> t <br /> JOB ADDRESS/LOCATIONff 4/C CENSUS TRACT <br /> I <br /> Owner's Name �' ]l .,y 1� n Phone 41f_ <br /> m 7 <br /> Address City ��G� <br /> -{ n r <br /> Contractor's Name License ��Phone J�•-+J � U,� <br /> TYPE OF'WORK (Check) NEW WELL, / / DEEPEN RECONDITION /_/ DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR '/ / PUMP REPLACEMENT 07( <br /> Other <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 1 <br /> Domestic/public Driven - Gauge of Casing M <br /> Irrigation _ Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout i <br /> Disposal Other Other Information <br /> ,Ge.go.hysical Surface Seal Installed By: <br /> PUMP INSTALLATION: R'Contractor_ <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: <br /> State Work Done <br />-PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter: Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply withiall 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/VD A FIN A INSP TIO <br /> SIGNED TITLE <br /> + (DRAW PLOT PLAN ON REVERSE SID ) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INVECTION PRASE I/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY F DATE $ <br /> ., <br /> " <br /> E H 1426 Rev. 1-74 1�/7; 2M <br />