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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF` OFFICE USE: 1601 E. Hazelton Ave.. , Stockton, Calif. 7 7e3g�u <br /> Telephone : (209) 466-6781 }^E ► t f�.- <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP FERMI Pexmit ;No.Y YV <br /> THIS PERMIT EXPIRES l 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 egulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION - CENSUS TRACT <br /> I <br /> Owner's Name r Phone ffy <br /> Address City <br /> W <br /> Contractor's Name icense <br /> Ccs 2, -?4' a <br /> TYPE OF WORK (Check) . NEW WELL DEEPEN/_/ RECONDITI N / / DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /� <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 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private !/Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 0 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection _�C Rotary Type of Grout _ <br /> Disposal Other Other Information V <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ' <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / _/ " S tate Work- Done \+ <br /> PUMP -.REPAIR: / / State Work Done <br /> U -� Alew G <br /> D TRUCTION �OFWE�L: Well_Diauieter aNy Approximate Depth <br /> Describe Material and'Pr cedure $Z 3—7161 <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local H alth District <br /> r <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 AN F NAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> P GROUT INSPECTION PHASE /FIN INSPECTION <br /> INSPECTION BY TE 'rn l "'�� INSPECTION BY v DATE <br /> I 7 Z.7: 2M <br /> E H 1426 Rev. 1--74 <br />