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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> os.,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 l YEAR FROM DATE 'ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a; permft to construct <br /> and/or instar, the work herein described. This appXication 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 e.adJ a�ra.oe m C. CENSUS TRACT <br /> Owner's Name Toe �:. ..,_,....._ ��. Phone <br /> Address ;? - <br /> 1� City ' <br /> Contractor's Name - ..� License # Phone , <br /> TYPE OF WORK (Check): NEW WELL.-L-7 DEEPEN '/-7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION/ / PUMP REPAIR'S PUMP REPLACEMENT <br /> Other ET — <br /> j <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY j <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 i <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven _ _ Gauge, of Casing . <br /> X Irrigation - Gravel Pack --Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal: Other Other Information ' <br /> Geophysical '- Surface Seal Installed 'B : ..., <br /> PUMP INSTALLATION: Contractor , "' j <br /> Type of Pump 4 <br /> Ut -,� H.P. �.Z- <br /> PUMP_REPLACEMENT: � /'/ State Work Done <br /> PUMP ,REPAIR: State Work Done <br /> F}E&TRUCTION_OF.WELL: Well Diameter Approximate Depth <br /> a -- Describe Material and Procedure <br /> I hereby agreel�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-best of m know e e belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO TING AND A FINAL INSP CT <br /> SIGNED IT]GE <br /> j-(PMR PLOT PLAN ON RnVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY / DATE ' <br /> ADDITIONAL COMMENTS: <br /> N <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION . <br /> INSPECTIONBY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 h/75 2M <br />