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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO$rOFFICE USE: Z16'01 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �1,-l.5"Gd <br /> THIS PERMIT EXPIRES- I YEAR FROM DATE ISSUED Date Issued <br /> Complete <br /> In <br /> Application is hereby made to the San{Joaquin Lo al Health District for a <br /> And/or install the work herein described. This application is made in compliancetwithnSan uioaquin� <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. , <br /> JOB ADDRESS/LOCA ..�ftJ ; jf' j4�G►/ � / , <br /> 7" A r CENSUS TRACT <br /> Owner's Name 1,A <br /> Phone j !� <br /> Address 6 � .� � ,�" � City 40 <br /> Contractor's Name <br /> License Phone. j ,/ <br /> JL � -- <br /> .r <br /> TYPE OF WORK (Check) : NEW WELL /'DEEPEN / / RECONDITION 17 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR /—/ PUMP REPLACEMENT /7 <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 /> INTENDER USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS UI <br /> Industrial l�Csble Tool Dia. of Well Excavation Cli <br /> ` Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> ligation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical. '^�' Surface Seal Installed B r� <br /> 3 <br /> PUMP INSTALLATION. Contractor <br /> Type of Pump <br /> . H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br />° PUMP .REPAIR., /7 State Work Done - -- - x <br /> ES•TRUCTION 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 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 TQ aRnMrTWO AMID A FIN �SPECTION. TITLE <br /> {DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I yFOR 'DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE §tom <br /> ADDITIONAL COMMENTS: <br /> PHASE II GB6UT INSPECTION PHASE III FINAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION. BY , DATE s 2d <br /> E H 1426 Rev. 1-74 <br />