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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. �1� <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 42130 CENSUS TRACT <br /> Owner's Name Phone 135 <br /> Address muo .� City A <br /> Contractor's Name cense #f �� Phone 3o/,-:33�..3 <br /> i <br /> TYPE OF WORK (Check) : •NEW WELL ' ; DEEPEN '/ / RECONDITION / / DESTRUCTION /_ qj <br /> PUMP INSTALLATION % / PUMP REPAIR / / PUMP REPLACEMENT /-7 LV <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 7 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 <br /> Disposal Other Other Information <br /> Geophysical % t Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor , <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done '^'' <br /> DES,TR_UCTION OF WELL`:; Well Diameter proximate Depth m <br /> T Describe Material and Procedure <br /> I hereby agree to comply with all, laws and regulations of the San Joaquin Loeal Health District <br /> and the State of California pertaining to or regulating well 'construction. �WiAin 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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE /2- <br /> ADDITIONAL <br /> 2ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIO PHASE III/FINAL INSPECTION 1 <br /> INSPECTION BY DATE INSPECTION BY ef. /L7 <br /> — DATE <br /> ''E_H 1426 Rev. 1-74 1777 2M <br />