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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF�'OFFICE USE: iii 1601 E. Hazelton Ave. , Stockton, Calif. <br /> r Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;r.7 SkJ <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 , CENSUS TRACT <br /> Owner's Name Phone � - cj 2-1 <br /> Address / City <br /> Contractor's Name , License # Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INST LAATTIjON // / PUMP REPAIR / / PUMP REPLACEMENT /- <br /> Other ASL ,Q U4460Lr <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 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing Q <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. N <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 6 Approximate Depth }� <br /> Desc4be Material and Procedure )t:j/jj <br /> �t <br /> I hereby agree to co ly with a 1 aws and regulations of the San Joaquin Local Health District <br /> and the State of Ca fornia pertaining to or regulating well construction. Within FIFTEEN DAIS <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 /> reformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 1;—Z <br /> ADDITIONAL COMMENTS: T <br /> PHASE II gWT ,1NSMCTION P <br /> EQ#vINSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE : <br /> E H 1426 Rev. 1-74 , f77 2M <br />