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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF:;OFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone; (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;�2,?� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE JSSUED' 'Date Issued /,2-3a-7.� <br /> (Complete In Triplicate) <br /> Applicgtion is hereby made to the San Joaquin Local 11calth 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 Regulations of the San Joaquin Local Health District. <br /> A) C _. <br /> JOB ADDRE S/LOCATION &AA CENSUS TRACT <br /> Owner's' Name e <br /> Phone ' <br /> Address S <br /> City ' ' <br /> ` Contractor's Name0"fiAa LicensePhone <br /> TYPE OF WORK -(Check) :. --*'-NEW-•WELL-I� DEEPEN _ <br /> ��.- ��` RECONDITION i7 DESTRUCTION /_7 <br /> f PUMP INSTALLATION# /7 PUMP REPAIR F7 PUMP REPLACEMENT %7 <br /> f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY F <br /> E SEWAGE DISPOSAL FIELD tit: -".CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE PRIVATE DOI�STICI,WELL ' PUBLIC DOMESTIC WELL <br /> INTENDED USE <br /> TYPE OF WELL-, r CONSTRUCTION SPECIFICATIONS <br /> Industrial - Cable-Too3�~ wD .. We -ExcavationDomestic/private li <br /> Drilled- We1I �Cnasig r <br /> S <br /> Domestic/public Driven ' _ Gauge of Casing <br /> It <br /> Irrigation „ , .,Gravel Pack ` � Depth of Grout Seal \ <br /> Cathodic Protection Rotdry ''Type of Grout <br /> t Disposal - 'f- Other k.gQther Information <br /> r Geophysical_- _ Surface Seal Installed ' <br /> i PUMP INSTALLATION: Contractor <br /> Type of -pump, - H.P. t: <br /> k PUMP REPLACEMENT: ' <br /> State Work'Done <br /> PUMP '.REPAIR: <br /> / / `State Wtork Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describa Material and Procedure <br /> and the g <br /> ' I hereby agree.._to ,compl,y.,.w1th-all-,laws .and-re ula•tions�of the- <br /> San-J-o-aquiri, Local Health'District <br /> k e State of California' pertaining,to or regulating well construction.. Within FIFTEEN DAYS <br /> rafter completion of my work ona new well'„I will furnish the San Joaquin' Local Health District a <br /> WELL DRILLERS REPORT of the well and;'nbtify :them before putting.the.-well' in.use.... The above <br /> ' <br /> information- is true to the ,best .of..my. knowledge and belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO GROJJTING 'AND A FINAL INSPECTION. <br /> SIGNED # TITLE <br /> PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> .,.. � ��, <br /> APPLICATION. ACCEPTED iY', DATE f �? <br /> ADDITIONAL COMMENTS <br /> PRASE-TI�GROUT-INSPECTION' - �' _ PHASE III FINAL INSPECTION - <br /> r INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74''_ <br />