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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR','OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> 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 /> i3 k:�6 . W w ,"( 2� - �� 0 S& -r 70--� ' . <br /> JOB ADDRESS/LOCATION vn 2,CENSUS TRACT <br /> Owner's Name WA. 6-4 Phone <br /> Address City <br /> Contractor's NametAA ;� License # s� Phone <br /> TYPE OF WORK (Check) : <br /> NEW-WELL-,/ ' .*,DEEPEN /-/-_.RECONDITION-/-�7Z DESTRUCT-ION /�- •- - - -- <br /> PUMP INSTALLATION / / PUMP REPAIR / / •=PUMP REPLACEMENT /-7 <br /> Other <br /> Ih <br /> ' GS <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CE SPOOL/SEtkAGE PIT - OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL !? PITBLIC DOMESTIC WELL , <br /> INTENDED USE TYPE OF CONSTRUCTION SPECIFICATIONS " 3 <br /> Industrial able Tool Dia. of Well Excavation l <br /> Domestic/private Drilled Dia. of Well Casing <br /> Do tic/public Driven Gauge of Casing x � <br /> rrigation Gravel Pack Depth of Grout Seal , <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information -- <br /> '�a <br /> Geophysical 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 /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure -Ij <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 DA�S <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 /> informatio 's true to t best of my knowledge and belief. I WILL/ALL FOR A GROUT INSPECTION <br /> PRIOR TO G 0 NG D IN INSPECTION. <br /> SIGNED '` TITLE <br /> / (ORAF PLOT PLAN ON REVERSE SIDE} <br /> PHASE FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY "' DATE / <br /> ADDITIONAL COMMENTS: p <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY � , _ DATE Vv 1 r <br /> E H 1426 Rev. 1-74 1177. _, ' 2M <br />