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SAN JOAQUIN LOCAL HEALTH- DISTRICT <br />; ,FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-b7$1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> s <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. 1$62 andk'the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION AlCENSUS TRACT <br /> Owner's Name ��V <br /> � �/s�L�r°/1 L.�, Phone ,3 <br /> Address t City <br /> Contractor's Name 6 License # Phone,5q <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/% RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION PUMP REPAIR/ / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTYILINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL p' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS N; <br /> Industrial f Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing �# <br /> Domestic/public Driven Gauge of Casing U ' <br /> 4 <br />�- Irrigation Gravel Pack Depth of Grout Seal 6� <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor edge <br /> Type of'Pump H.P. <br /> PUMP REPLACEMENT: . ' / / State Work Done <br /> L <br /> PUMP :REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth ' <br /> Describe Material and Procedure <br /> 4i <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 <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information .is true to the est a`f my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />?RIOR TO G VJNG jffDrA FjVAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PIAT PLAN ON REVERSE SIDE) , <br /> PHASE I <br /> OR DEPARTMENT USE ONLY <br /> E <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: _ <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 .. -Rev. 1-74 77- y 2M <br /> t <br />