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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFOFFICE 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 <br /> rir (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 workiherein 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 /> t <br /> JOB ADDRESS/LOCATION a CENSUS TRACT <br /> Owner's Name Phone J34,404- <br /> "dress <br /> 34,400"dress Y City Agooi <br /> Contractor's Name t # ` Licenses• 441 �' hone <br /> TYPE OF WORK (Check): NEW WEL PEN /77 RECONDITION /7 DESTRUCTION <br /> PUMP INSTALLATION UMP REPAIR /7 PUMP REPLACEME % T <br /> Other /_7 <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 v } <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECT TIONS <br /> Industrial .Cable Tool Dia. of Well Excavation <br /> `.FDomestic/private Drilled Dia. of Well Casing ` <br /> S Domestic/public Driven - Gauge of Casing <br /> s Irrigation Gravel Pack Depth of Grout Seal ` <br /> { Cathodic Protection Rotary Type of Grout <br /> } Disposal. �� Other Other Information <br /> Geophysical '° Surface Seal Installed B : 7,r. <br /> PUMP INSTALLATION: Contractor <br /> Type of PumprZ <br /> A <br /> PUMP REPIACEMENT: / / State Work Done <br /> PUMP !REPAIR: /_7 - State Work Dane °--- _ <br /> UL-TT$UCTION OF WELL: Well Diameter Approximate Depth <br /> De tribe Material anT Procedure - <br /> I hereby agree to comply with all laws and regal ions of tffe 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 ofthe 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 GR TINAND A:FINSPECTION. <br /> .JMSIGNED TITLE _ <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PRASE X DATE l/ %J 7S <br /> APPLICATION ACCEPTED BY G!' <br /> ADDITIONAL COMMENTS: <br /> � . PHASE II -GROUT INSPECTION ' PHASE III FINAL INSPECTIO <br /> INSPECTION BY 'i DATE INSPECTION BY DATE 1 <br /> i4 E H 1426 Rev.,1474 1-74 2M <br />