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,d 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. � <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 Oin an;eq. ] i2 and th Rules and Regulations of the Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION GU g&l,'�/ - /921-C. CENSUS TRACT <br /> Owners Name 2- V _. ���� Phone O <br /> Address f City �,--- <br /> Contractor`s Name License �0-;323Phone"'" �7g' <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/-7 DEEPEN /_/ RECONDITION 7 DESTRUCTION /7 <br /> PUMP INSTALLATION I / PUMP REPAIR J PUMP REPLACEMENT /? <br /> Other /-7 <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: \A n <br /> PUMP INSTALLATION: Contractor �k <br /> Type of Pump ,H.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> C16- I <br /> PUMP .REPAIR: State Work Done 116� <br /> -� <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 of my..knowledge and belief. I WILL CALL FOR A GROUT INSPECTIOR. <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> --- -----„ -a D WPjW. -PLAN 'ON RE REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 'l� DATE <br /> ADDITIONAL ICOM 4ENTS: <br /> PHASE I GROUT INSPECTION PHA I/FIN INSPECTION <br /> INSPECTION BY Z4 Z -?DATE INSPECTION BY D TE --9, -7 <br /> V76 <br /> E H 1426 Rev. 1-74 <br />