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SAN JOAQU'IN LOCAL°-HEAqH DISTRICT <br /> Fop, OFFICE USE: v 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209} 4615-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit no.� <br /> THIS PERMIT EXPIRE8: 1 'YEAR FROM DATE ISSUED Date Issued�`� <br /> (Complete, ,In Triplicate) <br /> Application is hexeby made to the San Joaquin Local- Ilealth 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. 18.62 and the Rules andRegula'tioms of the San Joaquin Local Health District. <br /> E/s Private In 1/2 mi N/�ovelgce,�1/2 mi: W/Union Rd. <br /> JOB ADDRESS/LOCATION S �`����c _ CENSUS TRACT <br /> Owner°s Name '"�^ Phone <br /> Address I - City ' <br /> Contractor's Namej. d ;� �o License Phone <br /> T <br /> 4 <br /> TYPE OF WORK (Check) i NEW WELL %T DEEPEN I? RECONDITION 17 DESTRUCTION <br /> PUMP INSTALLATION � PUMP REPAIR j / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES- PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PTT OTHER <br /> PROPERTY LINE - 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 11 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 i Other Other Information <br /> Geophysical ,' Surface Seal Installed B <br /> PUMP INSTALLATION., Contractor 0$ 141 a n �,C- C� � <br /> Type of Pump w. �` H,P. � <br /> PUMP REPLACEMENT: %/ State Work Done <br /> PUMP '.REPAIR:' L-7 State Work Done <br /> -'� 'T A roximate Depth _ <br /> ES-1RUC. ION OF WELL: -- .Ve11 Diameter pp p <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 GROUTING AND A FINAL INSPECTION. <br /> .SIGNED TITLE Q�Q k <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE .� � 7 <br /> ADDITIONAL COMMENTS: <br /> F PHASE 11 GROUT INSPECTION P S' FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION- BY DATE - 7�—— <br /> :yE H 1426 Rev. 1-74 1-74 2M .. <br />