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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOEjOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> I Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �< <br /> THIS PERMIT EXPIRES. 1 YEAR FROM DATE ISSUED Date Issued Aa-oe--7y <br /> I (Complete In Triplicate) <br />. , Applicdtion 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 ��`to� S' /i�v.�v; If CENSUS TRACT <br /> Owner's Name cu Phone <br /> Address City ' <br /> Contractor's Name License # Phone <br /> r - <br /> TYPE OF WORK (Check): NEW WELL RECONDITION /7 DESTRUCTION f7 <br /> PUMP INST CATION PUMP PAIR /� PUMp REPLACEMENT /T <br /> other' /✓� <br /> DISTANCE TO NEAREST: SEPTICtTANK SEWER LTNW PIT PRIVY <br /> SEWAGEiDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ts <br /> Industrial i Cable Tool Dia. of Well Excavation <br /> Domestic/private I Drilled Dia. of Well Casing _ - �,3,G <br /> Domestic/public I Driven Gauge of Casing - ,r j <br /> Irrigation Gravel Pack Depth of Grout Seal ' 14 . .. . . _� <br /> Cathodic ProtectionRotary Type of Grout - <br /> Disposal I Other Other Information , <br /> Geophysical. Surface Seal Installed BY: <br /> k PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: j/ State Work Done <br /> PUMP :REPAIR: /7 State Work Done _ <br /> z, <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth <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 Saa. 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 FI AL INSPECTION. <br /> SIGNED TITLE. <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE' ONLY <br />' PHASE I , <br /> i APPLICATION ACCEPTED BY , -� DATE. -� '" 2 <br /> ADDITIONAL COMMENTS.:- 'r qt <br /> PHASE'II GROUT;'-INSPECTION ;° P I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY. DATE -T M <br /> CA � <br /> 4 E H 1426 Rev. 1-74 2M <br />