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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOBjOFFiCE USE: 1601 E. Hazelton.Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7r� <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 andlthe Rules and Regulations. of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION,. . E,1 Gf,2 CENSUS TRACT <br /> Owner's Name q Phone av <br /> Address ! � 1 � n � <br /> k� `� City ibnd2jrLS Z,) <br /> Contractor's Name License Phone <br /> Phone <br /> TYPE OF WORK`, (Check): NEW-WELL '/7" DEEPEN /7 RECONDITION /7 DESTRUCTION /_j <br /> r P_UUMP INSTALLATION /—/ PUMP REPAIR /_7 PU e—MPLACEim <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 DONESTIC WELL, # <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> V <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Dome's tic/private' - Drilled a Dia. of Well Casing f <br /> I Domestic/public, , Driven Gauge of Casing l <br /> Irrigation Gravel Pack Depth of Grout Seal. � <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical V Surface Seal Installed BY: <br /> ,PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> xPUMP REPLACEMENT: T StateWork Done _+k. �r�Dui T ,c/ c ��i �c-�.A� J. • <br /> s <br />'-PUMP-:REPAIR: <br /> ES�TRUCTION 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 .weil 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 GROUTI G AND A FI I SPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS; ; <br /> PHASE II GROUT INSPECTION 1,1I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> a <br /> >: <br /> ~E H 1426 Rev. 1-741-74 2M <br />