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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Lor, OFTRE USE: 16r Hazelton Ave. , .Stockton, C,1'-"T. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. f/ , <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 Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> ,TOB ADDRESS/LOCATION CENSUS }TRACT <br /> Owner,'s Name /j,� ,�1� Phone <br /> Address :... City <br /> i <br /> Contractor's Name r �� License # Phone .`�� <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 TANK _ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD v ��- CESSPOOL/SEEPAGE PIT _ OTHER U)el <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION'S <br /> Industrial Cable Tool Dia. of Well Excavation % p� <br /> Domestic/private Drilled Dia, of Well Casingk2 42 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal �22� _ <br /> Cathodic Protection �^ Rotary Type of Grout <br /> Disposal Other Other Information � � -A <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 <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 /> ?RIOR TO GR UTING ANDA FINAL INSPE TION. <br /> SIGNED ,L�q� TITLE <br /> RAW PLOT PLAN 2P REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE -7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPE TION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY _ ' DATE <br /> D/f a I71 6L i� C a PLO�q.� 6,1 7 7 - 2M <br /> E H 1426 Reu_ , 1-74 1J t,J Ap .. .. <br />