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SAN JOAQUIN LOCAL'HEALTH DISTRICT <br /> FOFirOFFICE USE: /,) 1601 E. Hazelton Ave. , :-Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. S= 7!J <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 Regulations of the San Joaquin Local Health District. <br /> ' Jos ADDRESS/LOCATION CENSUS TRACT <br /> Owner"s Name Phone a4g —6z:?,f` <br /> Address � � -1�c' f.._..._,.,..._...... City <br /> Contractor's Name ' License ! 'Phone <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /? RECONDITION /? DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR {% PUMP REPLACEMENT /7 <br /> Other {7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWE LNES PIT PRIVY <br /> SEWAGE DISPOSMrFIELD bnr . CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE"—DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF LL CONSTRUCTION SPECIFICATIONS <br /> Indus7trial able Tool Dia. of Well Excavation [ A <br /> owestic/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 <br /> Disposal - Other Other Information <br /> Geophysical Surface <br /> Seal Installed BY: <br /> PUMP INSTALLATION: Contractor - <br /> IF Type of Pump .H.P.�� <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: /? State Work Done <br /> EES RUCTION 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 <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 GR I G ANR A F I VECTION. <br /> SIGNED TITLE <br /> Z V4 (DRAW PLOT PLAN ON REVERSE <br /> SIDOV <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY l' DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION ZPHASE III FINAL INSPECTION <br /> INSPECTION BY DATE / INSPECTION BY DATE <br /> ,i E H 1426 Rev. 1-74 1-74 2M <br />