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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. '� <br /> THIS PERMIT 'EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -a--7b� <br /> (Complete In Triplicate) <br /> j ,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 ie made in compliance with .San Joaquin <br /> County Ordinance' Nn, 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 2 0.2,!2 01 _2Z :D.C. 22.a . CENSUS TRACT - <br />` Owner's Name Phone , <br /> t <br /> Address City <br /> I Contractor's Name IT License # _746-el'Z Phone 17/6Z65 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/7 RECONDITION [7 DESTRUCTION f-7 <br /> PUMP INSTALLATION/ / PUMP REPAIR ;/-7PUMP REPLACEMENT 17 <br />} Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT 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 Q <br /> IndustrialCable Tool - - Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> n <br /> Domestic/public Driven - Gauge of Casing • 12 <br /> Irrigation _Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary .Type of Grout <br /> j Disposal Other Other Information ' <br /> 4 Geophysical Surface Seal. Installed 'B <br /> r <br /> � PUMP INSTALLATION: Contractor ' <br /> Type of Pump H.P. <br /> , PUMP REPLACEMENT / / State Work Done ' <br /> 9 <br /> PUMP (REPAIR: / / State Work Done <br /> ' DESjTRUCTION 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. -Wi.thin 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 TO G I4 40.a V IN ECTION. <br /> iSIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FODEPARTMENT USE ONLY <br /> PHASE I <br /> -21'.APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: 14 <br /> PHASE I GROUT INSPECTION PHA II . FINAL INS ECTION <br /> 'INSPECTION BY - DATE - r7�6 INSPECTION BY ' DATE a r <br /> E H. 1426 Rev. 1.74 <br />