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+� SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 1. 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 /> .,5� JO <br /> , AA/s <br /> JOB ADDRESS/LOCATION p I f�FENSUS TRACT <br /> 4, 1 <br /> Owner's Name Phone s?_ - j <br /> Address 17 ,934, City . <br /> Contractor's NameLicense #?.311 Phone <br /> TYPE OF WORK (Check) : NEW WELL LV <br /> / / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION / J PUMP REPAIR / / PUMP REPLACEMENT /7 <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 V " <br /> Domestic/private �c Drilled Dia. of Well Casing /y ' <br /> Domestic -- <br /> /public Driven � Gauge of Casing <br /> ^ Irrigation Gravel Pack Depth of Grout Seal (A/ <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B : <br /> PUMP INSTALLATION: Contractor r' <br />„ Type of Pump H.P. <br /> r . <br /> PUMP REPLACEMENT: / / 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 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 Ahe be my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIpR Ig AND F PECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE T� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II/'FINAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY DATE /77 <br /> E H 1426 Rev. 1-74 1ITT " 2M <br />