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FOF OFFICE USSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E: 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 / <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 /> fJOB ADDRESS/LOCATION Al. <br /> t- CENSUS TRACT <br /> Owner's Name Iz <br /> Phone <br /> Address <br /> .. ' ' City <br /> Contractor's Name <br /> License #, � l4A phone <br /> _ t <br /> TYPE OF WORK (Check) : NEW WELL/% DEEPEN '/ / RECONDITION / / DESTRUCTION / 7 <br /> PUMP INSTALLATION PUMP REPAIR S <br /> Other / ,/ PUMP REPLACEMENT /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY L <br /> SEWAGE DISPOSAL FIELD ' CESSPO'OrJSEEPAGE 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 <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 <br /> 124 <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done- ._ � �^ <br /> PUMP .REPAIR: /7-7--State Work Dorie' <br /> DESTRUCTION OF WEL�Well D ter <br /> ppro mate(Depth <br /> Describe Material and A <br /> 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 puttingthe. well in use.. The above <br /> information is true to the best of my knowledge and belief. I WILL C FOR A 'GROUT INSPECTION <br />'RIOR TO GR6VTING AND A INAL I SPEION. OOF <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> kPPLICATION ACCEPTED BY DATE r f <br /> kDDITIONAL COMMENTS: <br /> PHASE II G CTION P SE /FIN INSPECTIO <br /> INSPECTION BY ATE INSPECTION BY DATE/ � <br /> i <br /> E H 1426 Pm, I_'7A 1 1-7-7 <br />