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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 J <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit noll �i <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 Q CENSUS TRACT <br /> Owner's Name ti ,� f Phone <br /> Address /2LCity <br /> Contractor's Name License # C 3 Phone <br /> — s <br /> TYPE OF WORK (Check) : NEW WELL IX] DEEPEN /_/ RECONDITION /_/ DESTRUCTION /7 _ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES,-%00,n)' PIT PRIVY <br /> SEWAGE DISPOSAL FIELD S3oo" CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE%'?egjPRIVATE DOMESTIC WEL o0 PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> omestic/private Drilled Dia. of Well Casing <br /> D stic/public Driven Gauge of CasingEL <br /> Yathodic <br /> rigation. - Gravel Pack Depth of Grout Seal <br /> Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: PSI& e14G�V <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 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. 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 GROUTING AND A FIN INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) ; <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ' <br /> APPLICATION ACCEPTED B _ _ _{ _ DATE 67 <br /> ADDITIONAL COMMEN <br /> PHAS R INSPECTION Plikk I /FINAL INSPECTION <br /> INSPECTION Y DATE INSPECTION BY DATE <br /> 017 2M <br /> E H 1426 Rev. - 1-74 _ ,,. <br />