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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6782 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. U <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued L, <br /> (Complete In <br /> Application is hereby made to the San Joaquin Local rHealth tDistrict for apermit o 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 /> 1.5`701 1V•:>77W-C,-177r SO �. � <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name rPhone <br /> a <br /> Address <br /> City . <br /> Contractor's Name License # Phone ZL.9�Q <br /> z� <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/ / RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /^] <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC �SP <br /> SEWER �INES PIT PRIVY s <br /> SEWAGE ELD/ C 5SPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVA DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF.WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> amestic <br /> /public Driven Gauge of Casing _ <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout p ^, <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor IZO lyjE <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 <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 wellin use. The above <br /> information is true to the bes cf my knowledge and belief. I WILL CALL FOR A GROUT INSPECTIO <br />'RIOR TO GROUTI AND A FINA SP CTION. <br /> SIGNED <br /> • TITLE a , <br /> (DRAW YLOT PLAN ON REVERSE SIDE <br /> F R DEPARTMENT USE ONLY <br /> PHASE I , <br /> APPLICATION ACCEPTED BY DATE I- `Z- 3 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II /FI INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY '3=3 <br /> E H 1426 Rev. 1-74 1177 . 2M <br />