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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton 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 Issued 1— <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. 1.$62 and the Ru d Regulations of the San Joaquin Local Health District. <br /> �o <br /> JOB ADDRESS/LOCATION CENSUS TRACT. <br /> Owner's ,Name 'moi * Phone 77 O <br /> Address Cit <br /> Contractor's Name Licens/4") 3 Phone`f4611 � <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / 7 DEEPEN' /—/ RECONDITION /_� 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 \ <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 Casing <br /> Domestic/public Driven Gauge of Casing \v� <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 got H P. <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 A �_ <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ` DATE fj <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS II/FINAL ZNSPECTI N <br /> 1NSPECTION BY DATE I�N(SSPECTION BY DAT�Ep. <br /> / 9M <br /> E H 1426 Rev. 1-74 � k <br /> l <br />