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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 46`6-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. /�?_841 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued }1�-�7�' <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> Ind/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 <br /> CENSUS TRACT <br /> Owner's Name 'A .; v ` .�c-e� Phone <br /> Address �""� <br /> �� City - �J <br /> 'Contractor's Name � . - License fff_7_7Phone 2 <br /> TYPE OF WORK (Check): _ <br /> NSW WELL '/� DEEPEN/7 RECONDITION /-7 DESTRUCTION /7t h <br /> PUMP INSTALLATION /7 PUMP REPAIR /7—pump REPLACEMENT <br /> Other L/ <br /> DISTANCE TO NEAREST: SEPTIC TANK7,,�- SEWER LINES Q0•;o­ PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation t� <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection X Rotary Type of Grout 6r,, , •f <br /> Disposal Other Other Information s <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 > 1 <br /> ES•TRUCTION OF WELL: Well Diameter Approximate Depth 30 <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 TO GRO TING AND A 'F NAL IINSPECTION. <br /> SIGNED IL TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> F TMENT USE ONLY V i <br /> PRASE I <br /> i <br /> APPLICATION ACCEPTED DATE �' <br /> ` <br /> ADDITIONAL COMMENTrS: <br /> PHASE II,CROUT INSPECTION FHA III FINAL INSPEC ION <br /> INSPECTION BY DATE INSPECT IQN BY DATE <br /> `� nE H 1426 Rev. 1-74 <br />