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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFs;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 T <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local health District for a permit to construct <br /> and/or ins erein described. This application is made in compliance with San Joaquin <br /> Co <br /> u rdinance No. 1862 a he Rules and Regulations of tha San Joaquin Local Health District. <br /> JOB <br /> ,CENSUS TRACT <br /> Owner t o NameSA N <br /> a ujAjG , 0E EQ-0667YOV Phone 9^'/-ZZ'411 <br /> Address _ VL- f1 City kTpl/ <br /> Contractor's Name Qc' License Phone <br /> i <br /> TYPE OF WORK (Check): NEW WELL.'&7 DEEPEN -/_7 RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INST LATION / / PUMP REPAIR-/-7-pump REPLACEMENT /7 <br /> Other <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 , Cab able Tool Dia, of Well Excavation <br /> _ Domestic/grivate Drilled Dia. of Well Casing <br /> X 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: <br /> Contractor <br /> Type of Pump H.P. <br /> t <br /> PUMP REPLACEMENT: / /. State Work bone , <br /> PUNP_REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: <br /> 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. we11. in.use.... .The above <br /> informatio s true to the best of my..knowledge and belief, I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO ROU I D A SPECTIflN. <br /> SIGNED , TITLE <br /> ARAW PLOT PLAN ON REVERSE SIDE <br /> ' <br /> PHASE I <br /> FOR,-DEPART T USE ONLY <br /> AJ'P� LIGATION ACCEPTED BY DATE - , s <br /> ADDITIONAL COMMENTS: <br /> PHA I G NSPECTIO <br /> PHASE I FI INSPECTION <br /> INSPECTION BY �^ " ATE INSPECTION BY DATE <br /> e <br /> E H 1426 <br />