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L JOAQUIN LOCAL HEALTH DISTRICT „ <br /> FOR,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Califf . <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No- 22 1� <br /> THIS TERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued J z_f-2P' <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 j <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local :Health District. <br /> 09 !RJOB ADDRESS/LOCATION �O© jf� i t. CENSUS TRACT <br /> I <br /> Owner's Name Phone <br /> Address friC-z- City <br /> Contractor's Name License # � JPhone -QHS <br /> i <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 TANKSEWER LINES -1 / PIT PRIVY j <br /> SEWAGE DISP�FIELD C OOL/SEEPAGE PIT OTHER. C <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OfA&LL CONSTRUCTION SPECIFICATIONS <br /> I trial Cable Tool Dia. of Well Excavation <br /> omestic/private Drilled Dia. . of Well Casing <br /> Domestic/public Driven Gauge of Casing 6,0 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout ; <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> E - <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 re well"construction. Within FIFTEEN DA Ts <br /> regulating <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 A true to theest of. my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> .PRIOR TO G G . D A FaX IiNSPECIION. <br /> SIGNED TITLE + 7 <br /> (DRAW OT PLAN ON REVERSE SIDE <br /> FqE DEPARTMENT USE ONLY , <br /> PHASE I _ <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION f PHASE III/FINAL INSPECTION <br /> INSPECTION BY _ DATE INSPECTION BY DAT , - <br /> E H 1426 Rev. 1-74 ' 1177 2M <br />