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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 n <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 1 7 <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 /> JOB ADDRESS/LOCATION j <br /> • S ZZJAJ CENSUS TRACT ., <br /> Owner's Name � ,C- /�/�b iC(, Phone / ?a3 <br /> Address --- - 10 l"k.. City 4' -- <br /> Contractor's Name . ,, -,zJ License Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT / <br /> Other /7 <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_^____ - <br /> Domestic/public w Driven - w Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout (A <br /> Disposal Other Other Information ' <br /> Geophysical _ Surface Seal Installed By: <br /> U) <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump_ --- H.P. <br /> PUMP REPLACEMENT.:� y - State Work Done <br /> PUMP .REPAIR: ;. / / State Work Done <br /> DESTRUCTION-OF WELL: Well-Diame`ter- _ f Approximate Depth 'N <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 the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO NG AND FIW INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �._..- DATE % � <br /> ADDITIONAL COMMENTS: <br /> PHASE IT GgOUT INSPECTION PHA,5E II INAL INSPECTION - <br /> INSPECTION BY DATE INSPECTION BY / A DATE ZLI <br /> E H 1426 Rev. 1-74 <br /> 1177 _ 2M <br />