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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0_W OFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S=n2 <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued <br /> i I (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 /> r <br /> County Ordinance No.. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br />'r JOB ADDRESS/LOCATION CENSUS TRACT <br /> E Owner's Name . Phone G�7 <br /> Address �j `City <br /> r <br /> Z C:.� <br /> Contractor's Name s ' License # Phone?Y6'/�/, <br /> TYPE OF WORK {Ne_ek)1.­N_EW WELL; /Z -DEEPEN /? RECONDITION:/77 . DESTRUCTION /"j <br /> PUMP INSTALLATION / / PUMP REPAIR /-7—PUMP REPLACEMENT 17— <br /> Other' / <br /> — <br /> Other / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER n <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br />' INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial i table Tool Dia. of Well Excavation C� <br /> Domestic/private Drilled Dia. 'of Well Casing /O <br /> Domestic/public Driven Gauge of Casing /C> <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection. Rotary Type of Grout <br /> Disposal Other Other Information <br /> . Geophysical . e Surface Seal Installed By: - <br /> T <br /> PUMP INSTALLATION: Contractor .. <br /> Type of Pump H.P. --� <br /> 4 _ <br /> PUMP REPLACEMENT: / / State Work Done <br /> -PUMP:REPAIR:,,___.. __.;1/?,.„rState_Work .Done <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..well in use.. The above <br /> information is true to the.best of my.knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GR UTIN AND INSPECT N. <br /> SIGNED TITLE <br /> t {DRAW PLOT PLAN ON REVERSE SID _ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE a5 7s <br /> _ _ _ ........,.._,_._..,_ . . _..,.. . „ ... l <br /> ADDITIONAL COMMENTS: I <br /> PHASE II T3T?INSPECTION PHASE III/ TNAL INSPECTION <br /> INSPECTION BY 'DATE -7,INSPECTION BY DATE <br /> E R 1426 Rev. 1-74 1-74 2M <br />