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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. <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /�0-7f <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- No. 1862andthe Rulesnde2ulations of the San Joaquin Local Health District. <br /> .TOB ADDRESS/LOCATION �. CENSUS TRACT <br /> t i <br /> Owner's Name �i.�, `. �. Phone p Q� <br /> Address City I�d <br /> �/�-- <br /> Contrac�o,r's Name � � License #� :Z ;,�Phone .5j, g_3,4' <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN %/ RECONDITIONAL /_/ DESTRUCTION /_7 <br /> . ,, t �' PUMP INSTLATION .o PUMP REPAIR '/ / PUMP REPLACEMENT /_ <br /> �EkOther <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 -CONSTRUC.�ION SPECIFICATIONS ,. <br /> Industrial C-able-Tool•' Dia. -of--We11--Excavation-- <br /> Domestic/private Drilled Dia,. of Well Casing f <br /> Domestic/public' Driven Gauge of Casingr <br /> Irrigation Gravel Pack, Depth of Grout' Seal <br /> Cathodic Prote tion �,---RZ'tary %` Type of Gros' :0 <br /> Disposal Other �„`t Other Information <br /> Geophysical `+,� Surface SealInstalled By: <br /> PUMP INSTALLATION: Contractor ; AL <br /> Type of Pump ,.r .� - - H.P. <br /> -_ <br /> ._ Z;4 <br /> PUMP REPLACEMENT:: / / State Work Done <br /> r . . <br /> PUMP .REPAIR: / / State Work Done <br /> r <br /> DESTRUCTION OF WELL: Well Diameter 'r Approximate Depth <br /> Describe Material arid-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 IFF <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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) _ ---- '� <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE l� "~75 ` <br /> ADDITIONAL COMMENTS: t 1W <br /> PHASE II PLOUT INSPECTION PHAS /FIN INSPECTION ' <br /> INSPECTION BY DATE INSPECTION B DATE �,7� k <br /> \,E H1426 Rev. 1-74 f� �--� i�77 <br />