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FOR_- SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> 'OFFI"E USE 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _004W <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,S`/-7JK <br /> Application isy (Complete In Triplicate) . <br /> iereb 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 nd Regulations of the Sa Joaquin Local Health District. <br /> f + <br /> .TOB ADDRESS/LOCATION Jed ` <br /> CENSUS TRACT <br /> Owner's Name F3 <br /> Phone <br /> Address <br /> Address G <br /> City <br /> Contractor's Name�/i <br /> License e Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/—/_ i <br /> _ RECONDITION /� DESTRUCTION /� <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other I/ <br /> DISTANCE TO NEAREST.: SEPTIC TANK C)' <br /> SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL,FIELD . CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE <br /> PROPERTY :LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL— <br /> iEIPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial r-"^' Cable Tool Dia, of Well. Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation x Grave <br /> ___ Ca.thodi.c_.P..r.otection � l Pack Depth of Grout Seal <br /> _ � <br /> __ _.... Grave <br /> posal Rotary_ ,.. ..TYPe-of .Grout <br /> Dis <br /> Dis li sY Other Other Information <br /> p Y cal =� r-�r-— • w, , <br /> - .- Surface� Seal Installed B : - --- � <br /> PUMP INSTALLATION: Contra for w <br /> Type of. Pump <br /> E <br /> _ �. H.P. --- <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP -REPAIR <br /> /� / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material And Procedure Approximate Depth <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 onla 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 />?RIOR TO G OUTING A FINAL INSPECTION. <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> kPPLICATION ACCEPTED BY DATE �M . <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br />[NSPECTION BY DATE INSPECTION BY <br /> DATE <br />_E Hy1426 Rev_ 1-7G <br />