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SAN JOAQUIN LOCAL HEALTH DISTRICT <br />/ FOF OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �7 S3�kJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,--aa--22 <br /> '. (Complete In Triplicate) <br /> Application is Aereby 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? ,1 CENSUS TRACT ' <br /> Owner's Name Phone - -- d NC/v <br /> Address City . <br /> Contractor's NameLicense # �GG�/z Phone ,�?- <br /> i <br /> TYPE OF WORK (Check) : NEW WELLDEEPEN / / RECONDITION / / DESTRUCTION /-7PUMP INST�LATION / / PUMP REPAIR/ / FUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ?IT 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 i <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: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done _ <br /> PUMP -.REPAIR: / / State Work Done <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 r <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 GROUTIN AND A MAL INSPECTION. <br /> SIGNED TITLE _ <br /> _ PLOT PLAN ON REVERSE SIDE) ' <br /> FOR DEPARTMENT USE ONLY— . 77 <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ' <br /> ADDITIONAL COMMENTS: <br /> PHASE II T IN TION PHASE I I/ INAL SPECT O <br /> INSPECTION BY ���h INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br />