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_ SAN JOAQUIN LOCAL HEALTH DISTRICT �S <br /> FOH OFFICE USE: 1601 E. Hazel-ton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssueREC 22 V7 <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 CENSUS TRACT <br /> i <br /> Owner's Name Z,,, Phone 1{'j - 2,Z64;-/ <br /> i <br /> Address <br /> City yr. i air <br /> Contractor's Name7/ 2e License ��,� 2 Z Phone <br /> _ t <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION f_1 DESTRUCTION /- f <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /_7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK = SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL,FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LIN£�Q _ARIVATE DOMESTIC WELL .96_' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS lam ; <br /> Industrial _ Cable Tool Dia. of Well Excavation 11 ' � I <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing2e4 f:.e-uJ�// <br /> Irrigation Gravel Pack Depth of Grout Seal ot�SQ r <br /> Cathodic Protection Rotary Type of Grout,,,�C <br /> Disposal Other Other Information \"I <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. i <br /> PUMP REPLACEMENT <br /> / / State Work Done <br /> i <br /> _ I <br /> PUMP .REPAIR: <br /> / / 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 wellin use. The above <br /> information is true to th beE of knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO ING OD A F NS I <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: - CIS - DATE t Z <br /> PHASE GRO T INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE d <br /> E H 1426 Rev: 1=7`4 <br />