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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> LROCEa�r'JSE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209Y- 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.-2 7 /dek <br /> THIS PERMIT EXPIRES ,I YEAR FROM DATE •ISSUED Date Issued' <br /> i (Complete- In Triplicate) <br /> Application is hereby made to the San Joaquin Local .Heal.th District for a permit to construct <br /> 1 and/or install the work herein described. This application is made -in compliance with San Joaquii <br /> County Ordinance No. 1.862 and the Rules. and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 3Z V CENSUS TRACT <br /> R Owner's Name Phoney <br /> Address t City <br /> Contractor's Name � License # ` hh Ph'one'"� Q <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/ / RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other / / — <br /> DISTANCE TO NEAREST: SEPTIC TANK "7D— SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE FIT � OTHER = <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL X_ PUBLIC DOMESTIC WELL- <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS __ .� W <br /> Industrial. �w Cable Tool Dia.- of Well Excavation <br /> !t- <br /> Domestic/private Drilled Dia, of Well Casing <br /> 'Dome tic/public Driven Gauge of Casing _ ^� <br /> Irrigation Gravel Pack Depth of Grout Seal rj <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ' <br /> t 'Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> f 4� <br /> r-PUMP ,REPAIR: / / State Work Done . <br /> DESTRUCTION OF WELL: Well Diameter �Apprnximate Depth ,-.: <br /> Describe Material. and Procedure <br /> i <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 ''constructi.on Within FIFTEEN DAYS <br /> P g g g <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 nest of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION - <br /> PRIOR TO G OUTINGAND 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 �2z� DATE <br /> ADDITIONAL COMMENTS: - <br /> PHASE 11 GROUT INSPECTION PHASE II /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. - I-74 v/77 _ 2M <br />