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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0T:OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif, <br /> Telephone: (209) 4666781 r <br /> APPLICATION FOR WELL CONSTRUCTION OR ,PUMP PERMIT Permit No, ZL .�L,/tJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued _ 2 <br /> (Complete In. Triplicate) <br /> Application is hereby made to the Son Joaquin Local Health District for a permit to construct <br /> rind/or installs 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 �� d � ..CENSUS TRACT <br /> Owner's Name Phonefz <br /> Address City . f <br /> Contractor's Name ` icense„ v on l <br /> P <br /> TYPE OF WORK (Check): - NEW WELL 1jk-- EPEN -/_7 RECONDITION l7 DESTRUCTION f7 <br /> PUMP INSTALLATION "/ / PUMP REPAIR/77 PUMP REPLACEMENT /7 `--� <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD /eru CESSPOOL/SEEPAGE PIT. OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL" PUBLIC DOMESTIC WELL <br /> INTENDED. USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Q <br /> Industrial _( 7GTool Dia. of Well Excavation 42 77 <br /> �Tomestic a a/ private Drilled Dia. of Well Casing <br /> Domestic/public Driven -- Gauge of Casing - Y-�•= - _� - ---r- <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> 47 5— <br /> Disposal Other Other Information <br /> Geophysical Surface Seal 'Installed Bye <br /> PUMP INSTALLATION: -.',Contractor <br /> :Type .of Pump H.P. <br /> F <br /> PUMP REPLACEMENT: . State Work Done E <br /> PUMP .REPAIR: / / 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 an 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 .wel'l. in"use... .The above <br /> information is true to- the-best-of my knowledge and belief. I WILL CALL FOR A ,GROU'T INSPECTION <br /> PRIOR TO GROMNP.02 A FINAL ANSPECT ION. <br /> ` SIGNED TITLE <br /> (DRAW 'LOT PLAN .ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> � PHASE I - <br /> APPLICATION 'ACCEPTED BY � ' DATE 2 <br /> ADDITIONAL COMMMS: . . :- <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION ' <br /> 4,INSPECTION BY DATE INSPECTION BY DATE <br /> R H 1426 Rev. 1-74 <br />