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PI) <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOfi OFFICE USE-. f�`I 1601 E. Hazelton Ave. , Stockton, Calif. ' <br /> c 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 r7 <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 s', AJAIT R CENSUS TRACT <br /> Owner's Name /�, �. f ,v Phone o(� <br /> Address <br /> City ZS ),p/J <br /> Contractor's Name License 11,2, 1DPhoneo d <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION/ / DESTRUCTION /_7 <br /> PUMP INSTALLATION/7-/ PUMP RRPAIR / / PUMP REPLACEMENT ` <br /> Other /_7 <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 "1 <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 <br /> Irrigation` 1. `-^ Gravel Pack--- -D6ptE bf- Grout Sza1 <br /> Cathodic Protection Rotary Type of Grout �:'• �-, <br /> Disposal Other Other Information <br /> Geophysical Surface_Seal Installed: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. C <br /> PUMP REPLACEMENT: State Work Done Z: <_ �r s' <br /> PUMP REPAIR: e <br /> State Work Done <br /> DES-TRUCTION 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 GROU NG AND A F NAL INSPECTION. <br /> SIGNED TITLE `� ,,. <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE /T <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY G DATE 7 <br /> E H 1426 '; Rev. 1-74 ' 1177 - 2M <br />