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SAN JOAQUIN LOCAL'HEALTH DISTRICT <br /> Tow" CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: , (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7V-4,17 J0 j <br /> THISPERMITEXPIRES 1 .YEAR-FROM DATE ISSUED Date Issued 3-7 <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 Joaquin <br /> County Ordinance No.- 1862;and the Rules and, Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONS L ? � r CENSUS TRACT <br /> t . . <br /> Owner c s Name 1 �`��' Phone ��c� <br /> 4 Address. . w may. � � . City <7/ <br /> 11 �' License # 6�3 �4 0%0 <br /> Contractor's Name _ � � ._.._ �hane <br /> TYPE OP' WORK (Check): NEW WELL /? DEEPEN /7 RECONDITIO /J DESTRUCTION /� <br /> PUMP INSTALLATION / / PUMP REPAIR jo PUMP REPLACEMENT <br /> Other 1 / <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 y� <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation i 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 /> y . <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> `PUMP`rREPAIR: " /�:State Wa`rk`'Don <br /> PES•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 /> 4 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 .vvl TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FPR DEPARTMENT USE ONLY <br /> PHASE I i <br /> APPLICATION ACCEPTED BY i29- ° DATE <br /> ADDITIONAL COMMENTS: r <br /> PHASE 11 GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY i DATE <br /> E H 1426 Rev. 1-74 1-74 2M <br />