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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E`OF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ' 77- Y2yP <br /> Telephone: (209) 466-67$1 <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 Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District., <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> I <br /> Owner's Name _ Phone _ 379_� <br /> Address A r ' <br /> City �S Wen <br /> Contractor's Name fkwnla' an d1n_5 11in a CA.�L License Phone,5-_L2-Y/a,3/ <br /> ;i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/ / RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / I PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD_3-- CESSPOOL/SEEPAGE PIT OTHER (VaL <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 U" � <br /> ✓ Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation,., Gravel PackDepth o.f Graut Seal` <br /> Ca h dic Protection Rotary'"- Type"of�Grout <br /> Disposal Other Other Information hw 4a) <br /> Geophysical Surface Sealy Installed BY: <br /> 1' <br /> PUMP INSTELLATION: Contractor <br /> " <br /> Type of Pum I' <br /> YP P H.P. <br /> � H.P. <br /> PUMP REPLACEMENT: . / / State Work Done I <br /> I <br /> PUMP -.REPAIR: / / State Work Done 1 <br />)ESjRUCTION OF WELL: Well Diameter to;;/j/f Approximate Depth <br /> i� Describ Materialland roc dure <br /> I hereby. agree to comply with all laws and egulations of„the"San o uin Local'Health District <br /> and the State of California pertaining too or re_g-u .at g ell `construction. Within FIFTEEN DAYS <br /> atter 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 wellin use. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />'RIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON AEVERSE SIDE) O <br /> ZR DEPARTMENT USE ONLY <br /> PHASE I > E <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> P ,J;ekOUk INSPECTION/ PHA I / INSPECTIO <br /> INSPECTION B DATE INSPECTION BY DATE 7 <br /> 1127 2M <br /> E "H 1426 Rev. 7-74 <br />