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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. , 6--jt374),, <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 and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT � <br /> Owner's Name Phone yG - <br /> Address City <br /> Contractor's Name + <br /> License # Phone GZ--fE <br /> TYPE OF WORK (Check): NEW WELL DEEPEN/-7 RECONDITION %7 DESTRUCTION r7 <br /> PUMP INSTALLATION C/- PUMP REPAIR'/� PUMP REPLACEMENT /7 <br /> Other I I -- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY P-515ghlLp, <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PI�T��. 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 CA <br /> Irrigation Gravel Pack Depth of Grout Seal 4 <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 AIR: /7 State Work Done <br /> IIESTRUCTION OF F 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 INSPECTION <br /> PRIO_ R TO GROUTI A FINAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR <br /> PHASE I PARTMENT USE ONLY <br /> (Vol <br /> APPLICATION ACC B7j� DATE Z_ ` ZIPADDITIONAL COMMENTS: ZZ-evEx <br /> " <br /> PHASE II 9LOXiT INSPECTION. / PHASEAU FINAL INSPECTIO <br /> LV <br /> INSPECTION BY DATE 7.a -7(� INSPECTION BY DATE y <br /> E H 1426 Rev. 1-74 �t�?5 <br />