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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOh OFF=.SCE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM"IDATE "ISSUED Date Issued <br /> j (Complete In Triplicate) 2z-e- 13,o - 2-P + <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 Joaquili <br /> County Ordinance No. 1862 and the.Rules and Regulations of the San -Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION .,. r CENSUS TRACTJ7 IV <br /> 1 <br /> Owner's Name Phone ' <br /> Address /,zu Cit i <br /> y <br /> Contractor's Name ,41A License # Phone f . <br /> TYPE OF WORK (Check): NEW WELL, DEEPEN -7 RECONDITION /-7 DESTRUCTION f7 <br /> PUMP INSTALLATION "/ / PUMP REPAIR'/� PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK /QD 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 Cable Tool Dia, of Well Excavation " <br /> Domestic/private 1 Drilled Dia. of Well Casing <br /> Domestic/public + Driven Gauge of Casing <br /> Irrigation Gravel Pack" Depth of Grout Seal ! <br /> Cathodic Protection ,, v Rotary­� : -Type_of.,Groutw� <br /> f Disposal Other F Other Information <br /> Geophysical ` j " ;y� Surface Seal Installed B t <br /> PUMP INSTALLATION: Contractor44 <br /> .Type. .of Pump I A.P. . <br /> PUMP REPLACEMENT / State Work Done }• r '-�^ <br /> ,7 . <br /> PUMP ,REPAIR: State Work Done '{ - <br /> DESTRUCTION OF WELL: Well Diameter u?V'- , Approximate Depth <br /> Describe Material and Procedur6ll-* E .. Z< <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- "3.n.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 ROUTING, INAL -IN ECTI <br />' 'SIGNED TITLE ? <br /> (D PLOT PLAN ON REV10RSE SIDE <br /> OR .DEPARTMENT USE ONLY <br /> PHASE I / r--- <br />' APPLICATION ACCEPTED BY DATE . <br /> ADDITIONAL COMMENTS: t - <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY , DATE <br /> E 'H 1426 -Rev. "1-74 h/75 2M <br />