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S:N JOAQUIN LOCAL HEALTH DISTRICT <br /> FOP, OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Cali <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. G V <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued > -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 Joaqi <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District <br /> JOB ADDRESS/LOCATION 3 YS / `✓ r CENSUS TRACT <br /> Owner's Name <br /> �C �<GC m-t,.+ Phone <br /> Address <br /> city C' <br /> Contractor's Name j i0 License lid<,��'j�7 Phone / <br /> y(� i <br /> TYPE OF WORK (Check) : NEW WELL X-7 DEEPEN /-7 RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION /% PUMP REPAIR /-/-PUMP REPLACEMENT /7 <br /> Other / / — <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 , <br /> Domestic/public Driven Gauge of Casing E <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection }S Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP '.REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth j <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 <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 GR UTING D FIr INSPECTION. <br /> SIGNED TITLE �T VIZ <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I <br /> FOR TMENT USE ONLY <br /> APPLICATION ACCEPTED BYw DATE aj -/ Z <br /> ADDITIONAL COMMENTS: <br /> PHASE, I aROUT INSPECTION PHASEFI INSPECTION _ <br /> INSPECTION BY DATE INSPECTION BY! DATE - <br /> E H 1426 Rev. 1-74 <br />