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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR- OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _ 3� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application 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 Na 186 and the R es and .Re lata of te- n Joaquin Local Health District. <br /> s r r� ,•. � <br /> JOB ADDRESS/LLOCATION zL�-ccQ ,� Zc� 7V ej v ar- CENSUS TRACT .Z57_"0 3S <br /> 1 rye <br /> Owner's Name /L hone <br /> AddressiJ City �l� -�' <br /> Contractor's Name L('� License 11A & Phone <br /> i <br /> E <br /> TYPE OF WORK (Check) : NEW WELL%/ DEEPEN /_/ RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION PUMP REPAIR/ / PUMP REPLACEMENT 1_7 ' <br /> Other 41 <br /> ,y <br /> T 4) <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 /> INTENDED USE TYPE OF WELL CONSTRUCTION- ,SPECIFICATIONS <br /> Industrial Cable Tool Dia. 'of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven _ v Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection' Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installe B : <br /> PUMP INSTALLATION: Contractor <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 .well in use. The above <br /> information is trueNto the best of my knowledge and belief. I WILL XqLL FOR A GROUT INSPECTION <br /> PRIOR TO G UTING A VININSPECTION. <br /> SIGNED TITL <br /> DRAW- PL T PLAN 'ON REVERSE SIDE) ' '" '' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROVZJNSPECTION PHASE 14UFINAL,,INSPECTION <br /> INSPECTION BY INSPECTION BY Pit/ DATE <br /> E H 1426 Rev. 1-74 . <br /> 3/76 2M <br />