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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOROFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S- 311/Lc/ <br /> �J° <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued &L-as— <br /> (Complete <br /> L- s— , <br /> (Complete In Triplicate) `a 01 <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 Q /2I CENSUS TRACT j PS- +¢73T> U <br /> Owner's Name <br /> -! f'tl Phone &D <br /> ,Address _ / p <br /> •AddCity ' A17;0cam, <br /> Contractor's Name " g j License.# Phone " <br /> TYPE OF WORK (Check): NEW WELL ,/Tr DEEPEN '/? RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION /.PUMP REPAIR/? PUMP REPLACEMENT /7 <br /> Other Ll <br /> DISTANCE TO NEAREST: SEPTIC TANK /0-0. SEWER LINES -- PIT PRIVY -- <br /> SEWAGE DISPOSAL FIELD /OD CESSPOOL/SEEPAGE PITT 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 Groutge <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> y <br /> PUMP INSTALLATION: Contiractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP .REPAIR: /% State Work Done <br /> DES TRUCTION 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 INSPECTION <br /> PRIOR R TO GROUTING=AND A FINAL INSP CTION. <br /> SIGNED , TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ti DATE <br /> ADDITIONAL. COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BYDATE - _ INSPECTION BY �-, DAT <br /> E R 1426 Rev. 1-74 <br /> h .75 M <br />