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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ff OFFICE USE: ' � 1601 E. Hazelton Ave. , Stockton, Calif. <br /> I� 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 <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 an Regulations of the San Joaquin Local Health District. <br /> E JOB ADDRESS/,LOCATION �r� � � � • � `� <br /> CENSUS TRACT <br /> Owner's Name j` K Phone <br /> II � <br /> Address J ti q� ai �: City 42— <br /> icense # f"fid /Phone�. <br /> Contractor's Name �' i', ��<`��1 rl 6 � 9� �� � <br /> TYPE OF WORK (Check): NEW-WELL-k-j— DEEPEN /? RECONDITION /? DESTRUCTION <br /> € PUMP»INSTALLATION J -L PUMP REPAIR-/ PUMP REPLAC NT 17 <br /> Other / / - %1 <br /> DISTANCE TO NEAREST: SEPTIC TANK- 'SEWER LINES ,` PIT'PRIVY h <br /> 4 SEWAGE DISP SAL FIELD _` 4-`. _CESSPOOL/SEEPAGE'PIT OTHER <br /> PROPERTY LINE�•= PRIVATE-, DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> E INTENDED USE _,TYPE OF,WELL CONSTRUCTION SPECIFIC TIONS <br /> I dustrial A able Tool Dia. of Well Excavation c <br /> omestic/private. <br /> ` Drilled Dia. of Well Casing <br /> s Domestic/public L Driven Gauge of Casing } <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout . <br /> Disposal Other k Other Information <br /> F <br /> Geophysical ' Suif.ace Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of•Pump _ _S1 H.'P. <br /> PUMP REPLACEMENT: / / State Work Dane <br /> "/ StatWOrkdww--"PUMP�:REPAIt: O <br /> „�,- ;a <br /> r <br /> 4. <br /> ES;TRUCTION OF WELL: Well. Diameter" ¢ y 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 .toyor regulating well construction. Within FIFTEEN DAYS <br /> after completion`of my work`- on a new well; I will furnish the San Joaquin focal Health District a <br /> WELL DRILLERS REPORT of the"well and notify them before putting.. the..well in use. jThe above <br /> information P true to the-best of my knowledge and belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO TING AN FINAL INSPECTION. �--�� �f <br /> 'F TITLE / <br /> /�C <br /> SIGNED .�' <br /> �M (DRAW PLOT PLAN ON REVERSE SIDE <br /> F FOR DEPARTMENT USE ONLY ; <br /> PHASE IA-Z 1.7� <br /> APPLICATION ACCEPTED BY - - DATE a <br /> ' ADDITIONAL COMMENTS: .II <br /> PHASE IIjGROUT .INSPECTION PHASE IT (FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY LL DATE Z l � <br /> y E H 1426 Rev. 11,174 1-74 2M <br />