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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE§rOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. /� <br /> Telephone: (209) 466-6781 ` <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.�� c <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) e4�1 , <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 JoaquinE <br /> County,.4rdinance Noo;3862, and theYRules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 3 CENSUS TRACT 91- 0°10 '71 <br /> Owner's Name ,� -�- ,Q Phone <br /> Address 36 5--z, City <br /> Contractor's Name kmzk License #Poo 79Phane � -0& <br /> TYPE OF WORK (Check): NEW WELL ,/ DEEPEN17 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION / PUMP REPAIR /-7—pump REPLACEMENT <br /> Other I I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 5` . <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL N <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial t 1 Cable Tool Dia. of Well Excavation 40- <br /> Domestic/private Drilled Dia. of Well Casing 6 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> n _ <br /> Cathodic Protection Rotary Type of Grout 51� <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ` <br /> Type of Pump H.P. <br /> 4 <br /> PUMP REPLACEMENT: / / State Work Done ' <br /> PUNP .REPAIR: /7 State Work Done - <br /> PES TRUCTION OF WELL: Well Diameter r rr Approximate Depth 75 <br /> Des ib e 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 my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> j SIGNED TITLE <br /> ` (DRAW PLOT PLAN ON REVERSE SIDE) <br /> 7 FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYE DATE 7 ' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE Z' 'Z-f <br />` � E H 1426 Rev. 1-74 1-74 2M l <br />