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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOEjOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephoner (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 'Z-:7`* <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/LOCATIONCENSUS RACT F <br /> i <br /> Owner's Name Phone 461 , r 4 <br /> Address _ � 1�/L �Y`�- City j �, <br /> Contractor's Name ��lm License # Phone ' <br /> TYPE OF WORK (Check): NEW WELL/_7 DEEPEN '/-7. RECONDITION /-7 DESTRUCTION % 7 <br /> PUMP INSTALLATION j / PUMP REPAIR L_-PUMP REPLACEMENT /7 <br /> O1Fther / / -I ' ' <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 i. TYPE OF WELL # CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. ofNWell Excavation ! <br /> .;Domestic/privat:e j Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Packs Depth of Grout Seal <br /> Cathodic Protection'- �- ..Rotary . Type of Grout' R <br /> Disposal II Other Other Information <br /> Geophysical Surface Seal Installed B : <br /> i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. / <br /> I� <br /> PUMP REPLACEMENT: / / State Work Done 4 ' <br /> II .� .. <br />.<- PUMP !REPAIR: State Work Done <br /> eA <br /> ,DESTRUCTIONOF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> ;j i <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District 1 <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 i true to the-best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROVUNG #ND A,.&K& INSPYgHON. j <br /> SIGNED i TITLE <br /> itUORAW PLOT PLAN ON REVERSE SIDE <br /> j� FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY`: DATE <br /> ADDITIONAL COMMENTS: Ii <br /> PHASE II GROUT INSPECTION PHASE IIT FINAL INSPECTION <br /> INSPECTION BY ,j. DATE INSPECTION BY DATE <br /> t <br /> E H 1626 - 2M . <br /> � Rev. 1. 74 1 74 <br />