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1 <br /> 1 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORrOFFICE USE. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7.5,/7914 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued .5-, <br /> (Complete <br /> -.- <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 tha `work herein described. This application is made in compliance with San Joaquin <br /> County Ordinanceag. 1862 and the Rules andu�ans of an Joaquin Local Health District. � <br /> JOE ADD4011CON CENSUS TRACT <br /> r" <br /> Owner's Name Phone <br /> S- <br /> Address 5 :'°." City <br /> f <br /> i <br /> Contractor's Name ". License/ 2'.(6___`1 Phone7z,-i 43X> <br /> TYPE OF WORK (Check): NEW WELL/A-7�-`DEEPEN '/7 RECONDITION /7 DESTRUCTION 1 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY 1f <br /> SEWAGE DISPOSAL -FIELD CESSPOOL/SEEPAGE PIT OTHER k <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL v3 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ale Took. Dia. of Well Excavation V 1 <br /> !--Domestic/private Drilled Dia, of Well Casing l Cr9 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea '- <br /> Cathodic Protection Rotary Type of Grout _ --Y <br /> Disposal Other Other Information <br /> Geophysical 'Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT; / / State Work Done <br /> PUMP '.-REPAIR-:— -" / -State Work Done 7 _ <br /> ,VES TRUCTION OF WELL: Well Diameter _ r��, 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 540UTI ANDA NAL INSPECTION. <br /> SIGNED TITLE <br /> s (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY J <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PRASE II GROUT INSPECTION PHASE TIT FINAL INSPECTI2 <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> _ i <br /> 4_ 1 �,(� <br /> E H 1426 Rev. 1-74 `"'�74 2M <br />