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SAN JOAQUIN LOCAL IEALTH DISTRICT <br /> Fdfi;OFFICE USE; 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 1 Telephone: (209) 466 -6781 . <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.y] - <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> and/or install the work herein described. 1'2 7 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to constru�t <br /> This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 ani the Rules and Regulations of the San Joaquin Local Health District. <br /> I <br /> JOB ADDRESS/LOCATION Q <br /> CENSUS TRACT <br /> Owner'a Name R <br /> Phone ' �6-G �Z <br /> Address <br /> t City <br /> Contractor's Name ��' <br /> License <br /> SI <br /> TYPE OF WORK (Check): NEW <br /> WELL -/? DEEPEN /_7 RECONDITION /_ DESTRUCTION /_7 <br /> PUMP INSTALLATION /J(/- PUMP REPAIR'/ PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC 1TANK Ap/ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELI. PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF. WELL CONSTRUCTION SPECIFICATIONS �] <br /> Industrial i Cable Tool Dia. of Well Excavation 1 <br /> Domestic/private s Drilled Dia. of Well Casing <br /> Domestic/publict. Driven <br /> Irri bion Gauge of Casing � <br /> �f: Gravel Pack Depth of Grout Seal <br /> Cathodic Pr_otect_ion Rotary Type of Grout <br /> Disposal i Other Other Information <br /> Geophysical <br /> Surface Seal Installed 'B <br /> PUMP INSTALLATION;-'' Contractor <br /> f <br /> J Type. .of Pump H.P. <br /> PUMP REPLACEMENT: .. . .. j/ / State Work Done � <br /> PUMP 'REPAIR: State Work _ <br /> _,. . .� _ 1.. - <br /> Donees-�- - <br /> DESTRUCTION OF WELL; Well Diameter_.- <br /> Describe Material and Procedure Approximate Depth <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 FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE ,� I <br /> . DRAW PLOT PLAN ON REVERSE SID'E� _, ,— <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPAPP IL CATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE ' <br /> PHASE II GROUT INSPECTION <br /> PHAW.IIALEAL IYd5PECTION <br /> INSPECTION BY DATE _ INSPECTION BYDATE <br /> E <br /> �� 7 <br /> 1-74 H 1426 Rev. <br /> - <br />