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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> t FoTiZFFICE USE: 1601 E. Hazelton Ave.. , Stockton, Calif. <br /> Telephone: (209) 466-6781 f <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 2_3-,;%b j <br /> (Complete InTs;iplicate) i <br /> Application is hereby made to the San Joaquin Local Health District for a permit to ,construct t <br /> and/or install the.work herein described. This application .is made in compliance with San Joaquin ; <br /> County Ordinance No. 1862 aril the Rules and- Regulations of: ihe San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ,gip 5e CENSUS TRACT <br /> Owner's Name Aze <br /> f � <br /> Phone o <br /> Address " / y. r G ,. .. :. .: City <br /> Contractor'a Name License # Phone <br /> TYPE OF WORK (Check): NEW WELL _ _ <br /> /� DEEPEN '/?- RECONDITION /� DESTRUCTION � I <br /> PUMP INSTALLATION /—/ PUMP REPAIR /� PUMP REPLACEMENT /7 <br /> Other' — <br /> I <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 Q <br /> industrial i Cable Tool Dia. of Well Excavation �1I <br /> Domestic/private i Drilled Dia: of Well Casing <br /> Domestic/public 1 Driven Gauge of Casing <br /> Irrigation i Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal I Other Other Information , <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump A.P. <br /> ,I <br /> { t . <br /> PUMP REPLACEMENT: / / 'State Work Done <br /> PUMP.REPAIR: /7 State Work Done <br /> k <br /> f ESTRUCTION OF WELL: Well Diameter _^ Approximate Depth <br /> Describe Material and Procedure f-- <br /> ;1 <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 to the best-of my.knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTfNG A3b A,—FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> E2R_DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATi4�� <br /> E 7 <br /> ADDITIONAL .COMMENTS: ! ;, <br /> PHASE II GROUT INSPECTION PHASE '111 FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE �- -2e <br /> t E H 1426 . .Rev. 1-74 1-74 2M <br />