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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton, Ave. , Stockton, Calif. `a <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. AA&XL�' <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 /> 4 and/or instal] the work herein described. This application is made_ in <br /> . comp7_iance with San Joaquin <br /> f <br /> County Ordinance No. - 18,62 and the Rules and Regulations of the San Joaquin Local Health .District. <br /> i JOB ADDRESS/LOCATION r <br /> ENSUS 'TRACT <br /> Owner's Name <br /> (� J " �koPhone 3 - / <br /> Address-. : <br /> / City i <br /> Contractor's NaL ri <br /> License # p <br /> - -3 'hone =/ <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN / / RECONDITION /_/ DESTRUCTION /_" <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> tt <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES PIT PRIVY 1 <br /> SEWAGE DISPOSAL FIELD .35,�Z_A CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL <br /> Industrial Cable Tool CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Excavation <br /> Domestic/private Drilled —Z.L p ` <br /> Dia, of Well Casing rr 'V# <br /> Domestic/public Driven Gauge of Casing W <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary <br /> Type of Grout � , <br /> Disposal <br /> Other Other Information \� <br /> Geophysical Surface Seal Installed B ` <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP-' REPLACEMENT: E7 State Work Done <br /> UMP :REPAIR: <br /> / / State Work Done <br /> DESTRUCTION OF WELL. Well Diameter <br /> Describe Material and Procedure — Approximate Depth <br /> ------------- <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 <br /> WELL DRILLERS REPORT of the well and notify them before putting- thewell 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 G OUTING D A NAL INSPECTION, <br /> SIGNED TITLE <br /> f <br /> DRAW PLOT PLAN ON ERSE SIDE) M <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE II -GROUT INSP CTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE IN PECTION BY <br /> �A � DATE <br />. E H 1426 Rev. 1-74 , <br />