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_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> -TT-­OFFICE USE: 160,'1}'. Hazelton Ave. , Stockton, CaI�, <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 //- <br /> (Complete <br /> ssuedi/-(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 Joaquir. <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local <br /> Health District.. <br /> JOB ADDRESS/LOCATION /43 .Sa � � �-- ACC4C&" LEN S <br /> Owner r s Name '~ �/! =Phone �� <br /> Address Nt City eSeA- OI <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Ch6ck) : NEW WELL / / DEEPEN/_/ RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION % PUMP REPAIR / / PUMP REPLACEMENT / f <br /> Other / f <br /> DISTANCE TO NEAREST: SEPTIC TANK /2,r/ SEWER LINES /,2,rPIT PRIVY <br /> SEWAGE DISPOSAL FIELD ­1�1` CESSPOOLISEEPAGE 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 h <br /> Domestic/public Driven Gauge of Casing <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 d N <br /> Type of Pump H.P. __ <br /> 1 <br /> PUMP REPLACEMENT: / J 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 _4 FINAL INSPECTION. <br /> SIGNED " TITLE <br /> • (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I J r} ?-0707 <br /> APPLICATION ACCEPTED BY DATE /^G / "� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIgE P SE /FINAT, INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE -7 7 <br /> E H 1426 Rev. - J-74 <br /> pt'77 _ <br />