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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOReOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. S w <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ``7S-' <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 Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION - lellt441 CENSUS JRACT <br /> Owner's Name `Phoneme~D <br /> Address City <br /> Contractor's NameLicense # , Phone CIL <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /-7 RECO DITTON /_-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION 17 PUMP REPAIR /� PUMP REPLACEMENT 17 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK //9 SEWER LINES PTT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL •ECONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> V Domestic/private Drilled Dia, of Well Casing 70" <br /> Domestic/public Driven Gauge of Casing ,3 <br /> Irrigation Gravel Pack Depth .of Grout Seal e5i�jf <br /> Cathodic Protection Rotary Type of- Grout" _ ..� <br /> Disposal Other Other,Informati.on G <br /> Geophysical Surface Seal Installed BY: <br /> r <br /> PUMP INSTALLATION: Contractor # <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUNPIREPAIR: /-7 State Work Done _ <br /> E&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 <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 G OUTING AND4 FINAL INSPE, ON. <br /> SIGNED TITLE <br /> (DRAW EYE PLAN ON REVERSE SIDE r <br /> PHASE T R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE 3—/ 1 "7 <br /> ADDITIONAL COMMENTS: <br /> PHA Zj GROUT INSPECTION �..� P TAL INSPECTIO <br /> INSPECTION BY DATE .'� INSPECTI-0N_ DATE --3- <br /> i E H 1426 Rev. 1-74 1-74 2m <br />