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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0 Ci -�USE: 1601 E. Hazelton Ave. , Stockton, Calif. I <br /> -- '� Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ' -"I,+ vj <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued/2__&__Z17 <br /> (Complete :ln Triplicate) : <br /> I 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 incompliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and. Regula'tions of the San Joaquin Local Heal.th' District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT ' <br /> 1 <br /> Owner's Name k Phone <br /> Address - City `mac ]b xr <br /> Contractor's Name License ��� y'�� Phone7 � � <br /> TYPE Off` WORK (Check) : NEW WELL / / DEEPEN RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 1#1)t SEWER LINES PIT PRIVY <br /> 4 SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ` <br /> j PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL r .y CONSTRUCTION SPECIFICATIONS <br /> Industrial { Cable Tool Dia, of Well ExcavatiohK — <br /> k _ Domestic/private Drilled Dia, of Well Casing <br /> — <br /> Domestic/public Driven "' Gauge of Casing <br /> Irrigation # Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary ­-7Type of Grout <br /> -Disposal Other Other Information <br /> Geophysical Surface Seal Snstalled By: <br /> PUMP INSTALLATION: Contractor "? 3 - <br /> Type of 'Pump H.P. <br /> :P.UMP REPLACEMENT: / / State Work Done <br /> y PUMP REPAIR tate Work Done <br /> DESTRUCTION OF WELL:: Well Diameter Approximate Depth <br /> - - <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 TITL -' <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY YJA DATE 7-7 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P__,,_&ITMVINAL INSPECTION <br /> INSPECTION BY a DATE INSPECTION BY & DATE - <br /> oA7.7 '_ <br /> E H 1426 Rev- . 1-74 2M-- <br /> � - <br />