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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFsfOFFICE 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 l YEAR FROM DATE ISSUED Date Issued JO-'Clf- <br /> (Complete In Triplicate) � <br /> Application is hereby made to the Salt 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 na 2''16 If e? � 4 � CENSUS TRACT �] <br /> 'Owner 4 s Name i ev s <br /> im Phonet3 <br /> Address ., <br /> City -- <br /> Contractor's Name License #,,- <br /> _�.. ._ :. <br /> TYPE OF WORK (Check) ., NEW,WELL /7 DEEPEN -/-7 RECONDITION /? <br /> PUMP` DESTRUCTION /7 <br /> `INSTALLATION /� PUMP REPAIR /� PUMP REPLACEMENT <br /> Other /% ' <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL'— <br /> PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing � } <br /> Domestic/public---Driven-- ,,_. <br /> Gauge of .Casing._._.. 1 <br /> + Irrigation" Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout' -----� ,� <br /> Disposal�� y; � ��. Other Other Information _ �# <br /> `Geophysical " <br /> Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> . y <br /> PUMP:REPAIR: %� State WorklDotie ` ;' s} <br /> ES;TRUCTION 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-best-of- my knowledge and belief,. I WILL CAL4 FOR 'GROUT INSPECTION <br /> PRIOR TO GROU ING AND A F NAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID 1 <br /> FOR DAPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTS9 - DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY BATE INSPECTION BY DATE <br /> E H 1426 Rev. I-1e <br />