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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE-USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES I 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 Joaquini <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �f J-4-c k a�,c cj Fo CENSUS TRACT <br /> {, <br /> Owner's Name,. Phone <br /> Address s- j a. .. City <br /> Contractor's Namey7 (��[f <br /> I o r. C'o License �� Phone <br /> - i <br /> TYPE OF WORK (Check) : NEW WELI DEEPEN '/—/ RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other. / <br /> DISTANCE TO NEAREST: SEP C^TANKYjUd SEWER LINES 0 PIT PRIVY <br /> SEWAGE DISPOSAL FIELD <br /> _/2-p CESSPOOL/SEEPAGE PIT _ OTHER � <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation '' ,. <br /> _ Dome stic/private Drilled Dia. of Well Casing r <br /> Domestic/public Driven Gauge of Casing O f'fI Pv C.r <br /> Irrigation _,,4�:_ Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary —Type- of Grout <br /> Disposal - '. Other, i Other Information *6. <br /> Geoptaysical y- - ,-� T w -^ � . Surface_ Seal,Installed By:aL1 y/ <br /> PUMP INSTALLATION: Contractor „-�; ` . J <br /> Type of Pump H.P. <br /> PURE' REPLACEMENT: / / State Work Done - ° <br /> PUMP REPAIR: / / State Work Done, <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> I <br /> PP P <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 FOR A GROUT INSPECTION i. <br /> PRIOR TO GROUTING AND A FINAL SPECTION, <br /> SIGNED TITLE <br /> (DRAW"PUOT-PLAN ON REVERSE `SIDE) f <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 'w ® <br /> APPLICATION,, ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE I GROUT INSPECTION 71 2J PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE c 1 INSPECTION BY DATE <br /> ✓ v/77 _ 2M <br /> E H 1.426 Rev. - 1 7'4�•. �. <br />