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sf <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> L FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL.CONSTRUCTION OR PUMP PERMIT Permit No. S�J <br /> HIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued: _ <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. 1862 and the Rules and Regulations of the• San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION F CENSUS TRACT <br />{ Owner's Name David Ei nkPhone <br /> Address . City Lodi <br /> Contractor's Name ter-Wa-1License # 200794 Phone 948-8817 <br /> f <br /> TYPE -OF WORK- (Cheek) : NEW WELL-/7/ DEEPEN / '/ RECONDITION / / DESTRUCTION /7 <br /> k .PUMP INSTALLATION '/ / PUMP REPAIR / / PUMP REPLACEMENT /? <br /> I 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 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 Gauge of Casing <br />` Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection '.Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ' . <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <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 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 ofamy knowledge -and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR-TO GROUTING AND A TINAL INSPECTION. <br /> SIGNED TITLE <br /> DRAWL T',PLAN ON RE FRSE SIDE) Q „ ,,i. " <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br /> 3/76 2M <br />