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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> LFORQOFFICESE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMITPermit No.sF ,q✓ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /—Al -7k <br /> (Complete In Triplicate) <br /> Application is he eby 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 Jo4quin <br /> County Ordinance N Rules and Re ulations of the San Joa. A e? quin XLa, <br /> l Health District. <br /> JOB ADDRESS/LOCATION �, �_ <br /> �ENSUS TRACT <br />; .Owner's Name � � � � <br /> Phone <br /> Address JBaa c GoN, s� city _ <br /> Contractor's Name [L fes, 0C 0License # Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / . RECONDITION / / DESTRUCTION /'7 ' <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> F Other 1/7 f <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 CONSTRUCTION SPECIFICATIONS <br /> TIndustrial Cable Tool Dia. of We11'-Ekcavafion� ' <br /> 'Domestic/private t Drilled Dia. of Well Casing <br /> `Domestic/public Driven Gauge of Casing <br /> Irrigation - Gravel Pack Depthof <br /> Cathodic Protection Rotary Type of Grout. �� 4 <br /> Disposal <br /> Others Other Information <br /> -1 Geophysical ` ` Surface Seal Installed BY: <br /> PUMP' INSTALLATION: Contractor <br /> < <br /> Type of Pump ' H.P. ! <br /> PUMP, REPLACEMENT: / / State Work Done <br /> PUMP'REPAIR: i <br /> State Work Donea <br /> DEStTRUCTION OF WELL: Well Diameter Approximate-'Depth <br /> Describe Material and Procedure y <br /> 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 /> 4ter 'completion of my work on a new well, I will furnish the San Joaquin dotal Health District a <br /> WELL DRILLERS REPORT of the we'll 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 TNG AN FIN INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE_-S'IDE) } j <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE7�. <br /> ADDITIONAL COMMENTS: IV <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE �I/NSPECTION BY _ DATE <br /> E H 1426 Rev. 1-74- 1 /77 �Af <br />