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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209)' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. '? ':/ -7 y�, <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> ,! (Complete In Triplicate) <br /> Application is hereby mad 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 /> /I it <br /> JOB ADDRESS/LOCATION AQ ACe A CENSUS TRACT <br /> Owner's Name Phone <br /> 93.E- .3 gZo <br /> Address ` <br /> City E- <br /> Contractor's Name License #_355,31 3 Phone <br /> 1 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_% RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 2 SEWER LINES Z&jo.�_PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 004 CESSPOOL/SE�PAGE PIT OTHER. a �, <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL 4_Y- PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation 12 ) <br /> Domestic/private e Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing ' <br /> X Irrigation Gravel Pack Depth of Grout Seal r <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information ' <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump12 <br /> 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 DAIS <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 trite to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR T GR T AND NAL�INS�PECT.I�ON �SIGNED TITLEDRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I FOR DEPART NT USE ONLY <br /> APPLICATION ACCEPTED BY �7 DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE 11 GROUT INSPECTTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE Z, INSPECTION BY DATE <br /> E_H 1426 Rev. 1-74 ­ - .. .__.—. . ) I/Z7. _ 2M <br />