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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR QF CE USE: � 1601 E. Hazelton Ave. ,� . Stockton, Calif. <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, <br /> 1 ; (Complete In Triplicate) <br /> Application is•#hereby made tolthe 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/LOCATION CENSUS TRACT <br /> Owner's Name a4e ?�`��' Phone <br /> Address Alb /.LP- City • <br /> Contractor's Name C 00f License # -7i,�hone Y - 6 -G t <br /> TYPE OF WORK (Check): NEW WELL 17 DEEPEN/? RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION -f-= PUMP REPAIR -/_7 PUMP REPLACEMENT 17 <br /> x4 . Other / / <br /> DISTANCE" TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> 11 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 <br /> Domestic/public Driven Gauge of Casing <br /> � Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal . i Other Other Information . <br /> Geophysical +' Surface Seal Installed By: i <br /> PUMP INSTALLATION: Contractor "- <br /> Type of Pump - or H.P. ,� r <br /> PUMP REPLACEMENT: . E7 State Work Done <br /> PUMP 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 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 m ..knowledge and belief. I WILL CALL FOR A 'GROUT INSPECTION' <br /> PRIOR TO G ING'AND A FINAL INS N <br /> SIGNED / TITLE /` • <br /> D T-PLAN ON FRSE SIDE <br /> PHASE I _ ! FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -kit. DATE <br /> - <br /> ADDITIONAL COMMENTS: i ... <br /> PHASE II GROUT INSPECTION ,F PHASE III F- AL INSPECTION <br /> INSPECTION RY DATE INSPECTION BY DATE d - ..LS <br /> E H 1426 Rev. 1-74 _ IJ�� �M�✓ <br />