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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO-K;"OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209)" 466-6781 <br /> APPLICATION FOR WELL- CONSTRUCTION OR PUMP PERMIT Permit No. z6_31c5G) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued 6-//-7� <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 CENSUS TRACT <br /> Owner's NameIF <br /> ? Phone <br /> Address 7317 City <br /> Contractor's Name License # G /2 Phone <br /> TYPE OF WORK (Check): NEW WELL / f DEEPEN /7 RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTALLATION / PUMP REPAIR -/ PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK Sy Q ' 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 V <br /> Industrial. Cable Tool Dia. of Well Excavation <br /> �T Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing / <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> I Cathodic Protection Rotary Type of Grout �%A; <br /> Disposal Other Other Information ' ' <br />�! Geophysical Surface Seal Installed 'By: <br /> FPUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> , PUMP-REPLACEMENT: / / State Work Done .. <br /> PUMP 'nPAIR: / / State Work Done - <br /> ' <br /> DESTRUCTION OF WELL: Well Diameter - Approximate Depth <br /> �• Describe Material and Procedure <br /> � I hereby agree to comply with-alllaws and regulations of the San Joaquin Local Health District <br /> ; and the State of California' pertai-ting to or regulating well '-construction. Within FIFTEEN DAYS . <br /> ' after completion of my work on anew 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"bellef ' I WILL CALL FOR A GROUT INSPECTION <br /> 1PRIOR TO GROUTINq AM A FINAL SPE ION. -- . . <br /> `k SIGNED G TITLE <br /> W PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> l PHASE I <br /> APPLICATION ACCEPTED BY --DATE <br /> ADDITIONAL COMMENTS: u_ <br /> PHASE II GROUT INSPECTION PHASE,IIIIZINAL INSPECTION <br /> ! INSPECTION BY DATE -� INSPECTION .BY DATE ` <br /> E H 1426 Rev: 1-74 _ <br /> L17 <br />