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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 1 YEAR FROM DATE ISSUED Date issued �Sy,-G <br /> In <br /> Application is hereby made to the San (Joaquin eLocal rHealth tDistrict 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 /> .TOB ADDRESS/LOCATION a_. CENSUS TRACT <br /> Owner's ]Name - � ��, �' Phoneq".— <br /> .4 a�� �- <br /> Address �~ W City <br /> Contractor's Name <br /> to License # J 3 Phone <br /> TYPE OF WORK (Check) : NEW WELL/? DEEPEN / RECONDITION / / DESTRUCTION /? <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT /� - � <br /> Ocher / / ' <br /> DISTANCE TO NEAREST: SEPTIC TANK ' SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER r <br /> PROPERTT -LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> _ Domestic/private Drilled Dia. of Well Casing I] <br /> Domestic/public Driven Gauge of Casing `+}, <br /> Irrigation Gravel .Pack Depth of Grout Seal <br /> Cathodic Protection 7 Rotary"' Type of Grout <br /> Disposal — Other Other Information <br /> Geophysical / d" Surface Seal Installed By: E <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> - r' <br /> PUMP REPLACEMENT / / State Work Done W ' <br /> il/ State Work Done 7 s <br /> PUMP .REPAIR: <br /> DES,�� TRUCTION OF WELL: Well Diameter � <br /> 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 FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> _ <br /> DRAW. PLAN ON REVERSE SIDE •�J�.�•- ",.,"�--"!'I F, <br /> FOR DEPARTMENT USE ONLY . <br /> PHASE I <br /> APPLICATION ACCEPTED BY .: DATE <br /> ADDITIONAL, COMMENTS: - - <br /> PHASE II GROUT INSPECTION PHASE II/FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE / 6 <br /> E Fl 1426 Rev. 1,74 3/76 229 <br /> - � � <br />