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ca > . SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> o Telephone: (209) 466-6781 �,� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _Z� <br /> � <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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION (�1 � / ` �� y.'vvrr! 1 CENSUS TRACT <br /> Owner's Name d Sd'1✓ vY, �d �0"rte Phone <br /> Address *f? J d ' .1 City <br /> Contractor s Name ' 0�� u r License # / 7_1_ 'Phone j <br /> TYPE ?G -� <br /> OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT <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 Cable Tool Dia. of Well Excavation _ <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal 41 <br /> Cathodic Protection Rotary Type of Grout -10 <br /> Disposal Other Other Information _ <br /> Geophysical ( Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor U "" <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /F/ State Work Done A_r <br /> PUMP .REPAIR: / / State Work Done <br /> DES-TRUCTION OF WELL: 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 well in 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 GROUTING,AND A FINAL INSP ON. <br /> SIGNED ITLE <br /> (DRA P T PLAN ON RE RSE SIDE) <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE _ _ <br /> ADDITIONAL COMMENTS: <br /> PHASE II INSP CTION P E I/ NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY _ DATE <br /> 2M <br /> E H 1426 Rev. - I-74 -- <br />