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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORrOFFICE USE: 1601 E. Razelton 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 <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 $62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT /31 360 -C3 <br /> Owner°s Name Phone <br /> Address <br /> CM2=39 , pe�_Q City <br /> + Contractor's Named r License .?9g Phone Ykj-D(, <br /> TYPE OF WORK (Check): NEW WELL/? DEEPEN '/_/ RECONDITION /7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR /7 PUMP REPLACEMENT /7 <br /> Other /K <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 /> Indus trial-, °•, Cable Tool Dia. of Well Excavation <br /> Domestic/private. Drilled Dia. of Well Casing <br /> Domestic/public °Driven­ -__. ""�Gau a of Casin " <br /> Irrigation �. Gravel Pack DeGr- <br /> pth ofoiitg.Sea1 <br /> Cathodic Protection Rotary s Type of Grout <br /> Disposal Other _ Other Information <br /> Geophysical ! _ r Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor• <br /> j q .l Type of Pump i H.P. <br /> PUMP REPLACEMENT: El- State Work Done <br /> PUMP :REPAIR: /- State Work..Done <br /> ESTRUCTION OF WELL: Well'.DiameterA E ' � <br /> t Approximate Depth 4 <br /> Describe MateriA anal 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-Vest of my knowledge and belief. I WILL CALL OR A 'GROUT INSPECTION <br /> PRIOR TO TING AND &INAL -WRECTION. <br /> SIGNED14 <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> l F R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �/ DATE — 5 <br /> ADDITIONAL COMMENTS: <br /> PHASE II/GR0VT-INSPPCTjft PHASF INSPECTION <br /> INSPECTION BY -'DATE INSPECTION BY DATE <br /> ' E H 1426 Rev. 1-74 1-74 2M #' <br />