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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F_A­OFFYCE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ' <br /> 4 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 _3_7/ <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 t Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> I <br /> Owner's Name , Phone <br /> i <br /> Address City ` <br /> Contractor's `Name - r License #.:P7749/Phone <br /> 4 <br /> Lor— 7 <br />' TYPE OF WORK (Check) : NEW WELL DEEPEN %/ RECONDITION / / DESTRUCTION' /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / , PUMP REPLACEMENT / ' ;' <br /> Other <br />' DISTANCE TO NEAREST: SEPTIC TANK SEWER LIN S PIT PRIVY ' <br /> SEWAGE DIS -.FIELD C SSPOOL/SEEPAGE-PIT' OTHER <br /> I PROPERTY LINE " PRIVATE DOMESTIC-WELL - - PUBLIC-DOMESTIC WELL <br /> INTENDED USE �,;TYPF OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial able Tool Dia. of Well Excavation <br />!�mestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing'"""`._ <br /> Irrigation Gravel Pack Depth of Grout, Seal' <br /> Cathodic Protection Rotary Type of Grout 3 <br /> Disposal Other Other Information T <br /> Geophysical Surface Seal Installed By: <br />' PUMP INSTALLATION: Contractor <br /> Type of Pump _ H.P. # <br /> PUMP REPLACEMENT: / / State Work Done <br /> 's <br /> PU.MP.�REPAIR: .:. _.: /:r/State Work=Done--► .= = = - -- <br /> f/ <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth ate' <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 FIFTEENibAYS <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 wellin use. The above <br /> information yntrue to the b t of my knowledge and belief. I WILL C L FOR-A GROUT INSPECTION <br /> PRIOR TO GR AND F IN EUTION. R <br />, SIGNED + TITLE <br /> (D PLOT PLAN ON REVERSE SID-AT <br /> FOR DEPARTMENT USE ONLY <br />''PHASE I <br />,APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 7 <br /> E H 1426 Rev. 1-74 � f77 2M <br /> J� <br />