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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOk OFFICE USE: W 1601 E. Hazelton Ave. , Stockton, Calif. C� <br /> Telephone : (209) 466-6781 ��- c/YAJ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ��d-�/ <br /> (Complete In Triplicate) <br /> Ap iLo is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/ox al-i <br /> _� scribed. This application is made in compliance with San Joaquin <br /> C unt�i nce No. 1862 an the 'es a Rtgulati f the San Joaquin Local Health District. <br /> J CENSUS TRACT <br /> Owner's Name Phone <br /> Address / -3 �' City <br /> Contractor's NameCO-, rlicense �71ww Phong -Ij <br /> C7, <br /> i <br /> TYPE OF WORK (Check) : NEW WELL Z' DEEPEN /_/ RECONDITION / _ <br /> _/ 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 as <br /> 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: Contractor { <br /> Type of Pump H.P. r� <br /> V,; <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION 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 INSPECTION. <br /> SIGNED TITLE <br /> As A <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 9-77 APPLICATION ACCEPTED BY DATE � Q —7 7 <br /> ADDITIONAL COMMENTS: <br /> PHASA JI GROUT INSPECTION PHAS III/FINAL INSPECTIO <br /> INSPECTION BY ATE INSPECTION BY DATE <br /> E H 1426 Rev /74� � <br />