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�.� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE.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 1 YEAR FROM DATE ISSUED <br /> Date Issned27 <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 Rulesa Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION I�CU.$� 0-G � CENSUS TRACT <br /> Owner's Name "'IPhone <br /> Address (1 f City <br /> Contractor's Name License #VdC16,Od(;Phone <br /> v <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /. / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION /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 \ <br /> Domestic/private Drilled Dia. of Well Casing Q <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout k <br /> Disposal Other Other Information <br /> Geophysical Surf ace Seal Installed B <br /> PUMP INSTALLATION: Contractor °� � <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done � � e�G <br /> PUMP '.REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health th District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAIS <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 <br /> PRIOR TO GROUTING AND NAL INSPECTION. GROUT 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 GROUT INSPECTION P I FIN INSPECT N <br /> IN BY DATE INSPECTION B <br /> �°"r.�" DAT <br /> E H 1426 Rev. 1-74 <br /> -- ' 1 I 77 _ 2M <br />