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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. �- <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Jo Zy 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. 1662 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 16766 CENSUS TRACT <br /> Owner's Name Phone Za <br /> Address City <br /> Contractor's Name /R 0 License # 7460ZPhone ;7 <br /> TYPE OF WORK (Check): NEW WELL -aT DEEPEN -17 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR -/-7—pump REPLACEMENT /7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK --149 !a 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 <br /> ,Industrial Cable Tool Dia. of Well Excavation 16 <br /> Domestic/private Drilled Dia. of Well Casing _ _ fa <br /> Domestic/public Driven Gauge of Casing i <br /> Irrigation Gravel Pack Depth of Grout Seal - <br /> Cathodic Protection Rotary Type of Grout ,EN UN/TE <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: 0 S <br /> PUMP INSTALLATION: Contractor <br /> i Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: /7 State Work Done ; <br /> DESTRUCTION 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-bestof- my.knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTI A FINAL ION. <br /> SIGNED TITLE <br /> �. -{DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYDATE �— <br /> ADDITIONAL COMMENTS <br /> I PHASE IT GROUT INSPECTION PHASE III INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE z 7-5-- <br /> E <br /> E H 1426 Rev. 1•-74 ' 4/75 2M <br />