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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS 0 FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> t Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Pera:it No. 7,6- 4/Jp <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 4/V e. .f6 v CENSUS TRACT <br /> Owner's Name �} / ,l' � Phone j <br /> Address / a o 3 _�' `7�Q rf� St�� City <br /> Contractor's Name v License # 1 y3-7z.!Phone7 g)' <br /> TYPE OF WORK (Check): NEW WELL /? DEEPEN /—T RECONDITION /7 DESTRUCTION Lf <br /> PUMP INSTALLATION / 7 PUMP REPAIR fig-PUMP REPLACEHM f7 <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 DOMESTIC WELL ,rte <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Uj <br /> Industrial Cable Tool - Dia. of Well Excavation 04 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> _ Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Ca. <br /> Type of Pump r H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: LT State Work Done <br /> DESTRUCTION 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 knowledge�n belief, I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO TING AND A FIN PE <br /> SIGNE lr;�, TITLE <br /> D PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �, ` " DATE ' <br /> ADDITIONAL COMMENTS: <br /> PHASE II 9MINSPECTION HAS III FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE / <br /> R R 1474 /7M <br />