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/ 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. lSo2b <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 7 ,-3 7 5d GAV CENSUS TRACT <br /> Owner's Name Phone6 ',��a <br /> Address _ Jam' <br /> City �G /r{ <br /> Contractor's Name License Q �—P � .,2� iV <br /> � hone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/X/- RECONDITION /7 DESTRUCTION /_ <br /> PUMP INSTALLATION /li/' PUMP REPAIR I / PUMP REPLACEMENT /_7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK Q SEWER LINES PIT PRIVY y <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 /> y Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing ,Z <br /> Irrigation Gravel Pack Depth of Grout Seal fig` <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 /> DES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> f <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 thewell in use.. The above <br /> information is true to the, est of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR UTING AN ..�'A FI NSPECTION. <br /> SIGNED ' TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY, <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE - <br /> ADDITIONAL COMMENTS: <br /> PHASE II qPUT INSPECTION PHASE III/FINAL INSP TION <br /> INSPECTION BY DATE INSPECTION BY q DATE <br /> E .H 1426 Rev. 1--74 A if 2.M <br />