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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF:rOFFICE USE: .1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> ,APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z7-g 7,W <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSbED Date Issued <br /> .(Complete In Triplicate) <br /> Application is her p 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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ,� ( CENSUS TRACT <br /> Owner's Name FE U Phone <br /> Address <br /> City <br /> Contractor's Name - .....fN _.....__ License7Qy Phone - /,7 <br /> TYPE OF WORK (Check): NEW WELL M DEEPEN ,77 RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 2Y 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 Y&'` <br /> Domestic/private Drilled Dia. of Well Casing M <br /> Domestic/public Driven Gauge of Casing o5 , <br /> Irrigation Gravel Pack Depth of GroutLSetal _ �� <br /> Cathodic Protection _ Rotary Type of Grout <br /> Disposal. ' Other Other- Information O <br /> Geophysical Surface Seal Installed By: , <br /> PUMP INSTALLATION: Contractor A <br /> Type of Pump _ H.P. <br /> Pbr!T REPLACEMENT: State ` <br /> State Work Done <br /> PUMP !REPAIR: /-7 State Work Done <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 CALL FOR A'GROUT INSPECTION <br /> PRIOR TO GR0 T NG AIJD A MAL INSPE EON. <br /> SIGNED V.4ITITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) r <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I _ <br /> APPLICATION ACCEPTED BY DATE -7Z <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I '/FINAV INSPECTION <br /> INSPECTION BY DATE RZYJ INSPECTION BY DATE <br /> 1 E H 1426 Rev. 1-74 <br /> �1, <br />