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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF 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 <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 Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 7 } t a <br /> MNP CENSUS TRACT <br /> Owner's Name e� Phone <br /> Address /11A6 City � r_f 7a�✓ <br /> Contractor's. Name . _ u 4 `_ License Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /_/ DESTRUCTION /_ _ <br /> PUMP ;INSTALLATION /Z�— PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK - �14- SEWER LINES PIT PRIVY <br /> SEWAGE DISPO AS L FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINEV PRIVATE DOMESTIC WE'LL..`.,f,PUBLIC DOMES'T'IC WELL 6" <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 'a <br /> Industrial ; Cable Tool Dia, of Well ExcavatiUn <br /> Domestic/private 1 Drilled - ` Dia of Well Casing <br /> Domestic/public 1 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 /> GeophysicalSurface. Seal Installed By: <br /> k 1 <br /> PUMP INSTALLATION: Contrdctor t 1?f <br /> Type of 'Pump ;H.P. <br /> �. <br /> PUMP REPLACEMENT: / /. State Work Done ' <br /> PUMP .REPAIR: � <br /> • / / 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 my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING ANDiA FINAL INSPECTION. <br /> SIGNEDI,M��! I <br /> TITLE <br /> ! (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE <br /> FOR DEPARTMENT USE ONLY <br /> I� <br /> APPLICATION--ACCEPTED BY DATE - ]� <br /> ADDITIONAL COMMENTS: <br /> PHASE IIiGROUT INSPECTION IYRASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY f,,. ' DATE �,�/-e'.•` "' <br /> L E H 1426 Rev. , 1--.74 6 7.7 2M <br />