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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOPsrOFFICE USE: 1601. E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT .Permit No.." <br /> F tY <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3_ <br /> (Complete In Triplicate) <br /> p � <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 trade 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/LOCATIONL CENSUS TRACT # <br /> Owner's Name _ ._ Y� `., Phone <br /> AF <br /> Address.- c City , <br /> Contractor's Name License # e/ ?" Phone _ C4,)- *29-z <br /> TYPE OF WORK (Check): NEW WELL '/-7 DEEPEN -/-7 RECONDITION /7 DESTRUCTION /'7 <br /> PUMP INSTALLATION / / PUMP REPAIR /)C� PULP REPLACEMENT /7 j <br /> Other <br /> L <br /> R DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY . <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OT41ER . • <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC 7WE -L <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 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of 'Grout : t <br /> Disposal Other Other Information <br /> g Geophysical Surface Seal Installed By: <br /> x <br /> � R <br /> PUMP INSTALLATION: Contractor ,. <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP,`.REPAIR: L)el State Work Done d <br /> ES•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> a i <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 an e1 ef. I-WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU ING AND A FINAL INSPECTIO <br /> SIGNED <br /> h R <br /> {DRAW -P ON REVER -SIDE) <br /> F_Q)r DEPARTMENT USE ONLY <br /> PHASE I APPLICATION ACCEPTED BY DATE 3 <br /> 'ADDITIONAL_ COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION i <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> w <br /> E H 1426 Rev. 1-74 <br /> y,!' 1-74 2M <br />