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SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> FOE OFFICE USE: 160 . Hazelton Ave. , Stockton, Ca:�. �vG(� <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /7�1-<"7 <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 Re ulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION A�� 16a,11A C-�y� SUS TRACT <br /> Owner's Name .. �► ift� f Phone <br /> Address y1 -Al <br /> City <br /> Contractor's Name � 01Licensey� "� Phone/ Y�l <br /> TYPE OF WORK (Check) : NEW WELL /Z:7�DEEPEN / / RECONDITION /_/ DESTRUCTION /7 _ <br /> PUMP INSTALLATION / / PUMP REPAIR / J PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES PIT PRIVY <br /> SEWAGE DISP SO AL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial i—Cable Tool Dia. of Well Excavation I _ (r <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> 1---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: �"-�C <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION )F WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 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 GROWING AND A FINAL INSPECT1,0 <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY j DATE /lam <br /> 0!77 _ 2M <br /> E H 1426 Rev- 1-74 <br />