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kSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOReO,FFICE USE: 11601 E. Hazelton. Ave, <br /> Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> � -lu IBJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued <br /> k � (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 /> r JOB ADDRESS/LOCATION <br /> ENSUS TRACT <br /> Owner's Name Cy <br /> Phone <br /> Address <br /> City 1 <br /> Contractor's Name <br /> License # ;Phone, <br /> TYPE OF WORK Check _ <br /> (Check): NEW WELL / EEPEN '/T RECONDITION /� DESTRUCTION <br /> PUMP INSTALLATION / PUMP REPAIR 1-7—Pump REPLACEMENT /7o, �. <br /> f7- <br /> Other' / (^RC1 <br /> DISTANCE TO NEAREST: -SEPTIC-TANK <br /> SEWER LINES PIT PRIVY <br /> SEWAGEDISPOSAL FIELD CESSPOOL/SEEPAGE PTT <br /> OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool.4,, <br /> �mestic Dia. of Well Excavation <br /> /private i Drilled Dia, of Well Casing <br /> _ Domestic/public i Driven Gauge of Casing <br /> Irrigation Gravel Pack, • Depth of Grout Seal <br /> Cathodic Protection Rotary e Type of Grout .� ..� <br /> Disposal Other �� <br /> Other Information <br /> —Geophysical _ Surface Seal Installed S �. <br /> .� <br /> PUMP INSTALLATION; Contractor <br /> Type of Pump H.P. <br /> s-1 ,0 <br /> PUMP REPLACEMENT: / / State Work Done Y_ <br /> PUMP '.REPAIR: 17 State Work Done <br /> ES�TRUCTION OF WELL: Well Diameter' <br /> pproximate Depth-` <br /> Describe Material and Procedure ------ <br /> i -r- <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 FORA GROUT INSPECTION <br /> PRIOR TO GROUTTWC AND A F NAL INSPECTION. <br /> SIGNED <br /> TITLE <br /> F. (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY Z ' <br /> ADDITIONAL COMMENTS: DATE -3 G'7 <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY PHASE III FINAL INSPECTIO <br /> DATE INSPECTION BY C. <br /> DATE S ,� <br />—. E H 1426 Rev. 1-74 <br />