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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 '2-,7-'7 <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 JQaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Y - Phone Pa <br /> Address <br /> 1 - z.,� City cs <br /> _ ,� <br /> License Phone .�— <br /> Contractor s Name <br /> TYPE OF WORK (Check) : NEW WELL/DEEPEN / / RECONDITION / / DESTRUCTION /7 al <br /> AL <br /> PUMP INSTLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT / W <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CE SPOOL/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 <br /> Irrigation Gravel Pack Depth of Grout Seal 15-r <br /> Cathodic Protection L-.- fltary 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 .REPAI / / State Work Done <br /> D .TRUCTION OF WELL: Well Diameter Z -car>u7� Approximate Depth <br /> S <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 thewellin use. The above <br /> information true to thelbest of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO IN D NAL INSPECTION. <br /> SIGNED(__-e,fe TITLE <br /> W PL T PLAN ON RE RSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I / 7 <br /> APPLICATION ACCEPTED BY Gv DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY TE <br /> E H 1426 Rev. 1-74 <br />