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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.'s-gj 7 <br /> i <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 and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone 3 �} - 7 <br /> Address �, .�r3 City �P7 ' <br /> Contractor's NameiCY ( 7 <br /> License ��f � 7 Phone�] 9-�T' C <br /> LL <br /> / / RECONDI' <br /> TYPE OF WORK (Check) : NEW WELL/� DEEPENi � TION / DESTRUCTION <br /> PUME. I1�STALLATION /I/ PUMP REPAIR .� P+UMP REPLACEMENT /-7 ' <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES V PIT PRIVY <br /> SEWAGE DISPOSAL FIELD, C$-OSPPIT OTHER <br /> PROPERTY LINE PRIVAfIE DOMESTIC WELI;�.' PUBLIC DOMESTIC WELL - <br /> 'INTENDED USE TYPE OF WELL "�_GQNSVRUCTION SPECIFICATIONS <br /> 3Industrial i Cable Tool Dia. of WelI Excavation <br /> Domestic/private I Drilled Dia. of Weil7,,,.�-Caslingz. <br /> Domestic/public I Driven r <br /> Irrigation ) Gravel Pack Depth of Grout-Seal <br /> Cathodic Protection Rotary jType of Grout <br /> 'Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> E <br /> PUMP INSTALLATION: Contractor <br /> Type of'. Pump H.P <br /> PUMP REPLACEMENT: /7-state Work Dona <br /> PUMP .REPAIR: /,V- State Work Done,? <br /> DESTRUCTION OF WELL: Well Diameter -'' Approximate Depth <br /> ,. <br /> Describe Material arid' 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 dr regulating well'-construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well. !,! will furnish the San Joaquin Local Health District a ` <br /> WELL DRILLERS REPORT of the well and notify'tthem before putting the -well in use. The above <br /> information is true to the best of- my knowle`dge� and belief. I WILL CALL FOR A GROUT INSPECTION. APRIOR TO GRO NG �ND A INSPECT ON. 1 K <br /> SIGNED TITLE <br /> WP PLAN 'ON RSE SIDE : . 'I ' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ;- - <br /> APPLICATION ACCEPTED BY C`' DATE �3 <br /> ADDITIONAL COMMMS <br /> PHASE II GROUT INSPECTION E PHASE TI FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE r o- <br /> E H 1426 Rev. .i-74 <br />