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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. . <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,� p � <br /> THIS 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 nd Regulat. ns of a San Joaquin Local Health District. <br /> JOB ADDRESS/LO TION ✓ �,eENSUS TRACT <br /> Owner's Name Phone <br /> AddressA �f-J Cit , <br /> Contractor s'Name License '6 4-119i 3 one-ltg�,r <br /> i <br /> TYPE OF WORK (Check): NEW WELL DEEPEN / I RECONDITION / DESTRUCTION I? <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT <br /> 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 FDriven Ga g,of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection I Rotary Type of Grout <br /> Disposal Other Other Information \ R <br /> Geophysical Surface Seal Installed By: \vim• <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: - / / State Work Done <br /> �, o fIN <br /> State Work Done <br /> 6ES•TRUCTION OF WELL: Well Diameter oximate 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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED C'i� TITLE <br /> W Puff PLAN ON REVERSE SIZE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br />*.APPLICATION ACCEPTED B DATE e 3/-4 <br /> ADDITIONAL aCOMM�NTS: r <br /> i -,., �- PHASE II I SPECTION PHASE III/FINAL INSPECTION . : <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> !E-H 1426 Rev. 1-74 C�/*� b 1 / : <br />