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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR,OFFICE USE:—,- 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. - 1 e <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued7gr <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/oriinstall the work herein 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 /> jgff2-- �. <br /> JOB ADI3RESS/LOCATION 5fl <br /> 7, r7c O� 12 CENSUS TRACT 4 z. -/(gyp <br /> Owner's Name <br /> z— Phone <br /> Address /r' 1 Gv Q' City <br /> Contractor's Name ,License # Phone &_49o3 <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN-j-7 RECONDITION /7 DESTRUCTION'/? <br /> PUMP INSTALLATION /T7--PUMP REPAIR / / PUMP REPLACEMENT 17 <br /> Other /% . <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES <br /> PIT PRIVY <br /> SEWAGE DISP AL FIELD CES--SPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE W 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 /> tomestic/public 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 /> Geophysical Surface Seal Installed By* . <br /> a r <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ( H ` <br /> .P. _ s� <br /> PUMP REPLACEMENT: j_/ State Work Done <br /> PUMP ,.REPAIR: /_7 State Work Done <br /> ES•TRUCTION 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 f <br /> WELL DRILLERS REPORT of the well and notify them before putting the- well in .use. The above f <br /> information is true to the best-of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GOUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE y- <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYA]&0i TE <br /> ADDITIONAL COMMENTS: 1 <br /> PHASE II GROUT INSPECTION /)11&0 H&SEIIII/F114AL INSPECTION <br /> INSPECTION BY DATE INFWAON. Y DATE <br /> 4 E H 1426 Rev. - 4 1- 4 2M <br /> 1-7 . <br />