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04- 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. ,&-S/1f4J <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/LOCATIONJ�� lc�' TG�� '� CENSUS TRACT <br /> Owner's Name Phone <br /> AddressCity <br /> Contractor's Name c�cd� �� License #.Z"7 Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN / / RECONDITION DESTRUCTION <br /> PUMP INSTALLATION _t3;T PUMP REPAIR/ / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PTT PRIVY <br /> SEWAGE DISP05 FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS I. <br /> Industrial Cable Tool Dia. of Well. Excavation <br /> > Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing !Z <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection X Rotary Type of Grout <br /> Disposal. Other Other Information <br /> Geophysical. Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor _ /- l� .al' <br /> Type of Pump_ y`6r`i � H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / 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 a st bf my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AN CT IO . <br /> SIGNED 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 /> PHAS ; II GRO T INSPECTION P I/FINAL INSPECTION' <br /> INSPECTION BY DATE / INSPECTION B DATE <br /> E H 1426' Rev. 1-74 <br />