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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> EOR OFFICE USE: ' 1601 E. Hazelton Ave. , .Stockton, Calif. <br /> Telephone : (209) 466-6781 r/ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued J 32 <br /> (Complete In Triplicate) <br /> Application is Aereby 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 �3 O C�C� o- p CENSUS TRACT <br /> Owner's Name `A <br /> �d � Phone <br /> Address _ Q� �(� City <br /> Contractor's Name i License #PA1046( Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/_/ RECONDITION /_7 DESTRUCTION /_7 <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 fy <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL "w <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 <br /> Cathodic Protection _ Rotary Type of Grout _ <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor<2� � <br /> r <br /> Type of Pump H.P. ,.--- <br /> PUMP REPLACEMENT; State Work Done del- <br /> PUMP <br /> de <br /> PUMP�.REPAIR: / / State Work Done <br /> DES-T�__ iRUCTION 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 AtQ A ENTAL INSPECTION. <br /> SIGNED � TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE Z2f—7jj <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION. PHA S I/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 717 7: 2M <br />