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el-tt SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> T1,D 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 I 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 ZD - CENSUS TRACT <br /> Owner's Name - - -- - Phone <br /> Address V) City tsuNLQ10 <br /> Contractor's Name V- k% j 12�'ZC)S License #-1c Phone <br /> a <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN RECONDITION RECONDITION / / DESTRUCTION /_ _ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK L-0-_ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD L! 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 /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing D_ c.„ps, - <br /> Irrigation Gravel Pack Depth of Grout Seal 0% <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 WE L: dell Diameter Approximate Depth <br /> Describe Mate ial a�Procedu e <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 TO OUTING AND A FINAL-INSPECTION. <br /> SIGNED 1)1L�. TITLE , ,- 1�AX����l <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I f �/ <br /> APPLICATION ACCEPTED BY DATE 1 �4 <br /> ADDITIONAL COMMENTS: <br /> PHAS -GROW INSPECTION . PHASE IAI/FINAV INSPECT ON <br /> INSPECTION BY ATE $ INSPECTION BY DATE -7(( <br /> E H 1426 Rev, 1-74 <br /> rw`'` 14 U' kr-W, 6/7 ./ 2M <br />