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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF, OFFICE USE: . 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 1F:fS ?Z- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued `7 7 d <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 /> Owner's Name T ��� �� Phone <br /> Address Q City <br /> Contractor's Name ''" License <br /> 4;;%V Phone I /'r <br /> TYPE OF WORK (Check) : NEW WELL /i�--DEEPEN / / RECONDITION / / DESTRUCTION / r _ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT / 7 <br /> Other /7 <br />'DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 20f- 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 r <br /> Domestic/private Drilled Dia. of Well Casing <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: 6 :� r <br /> LPUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> s <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done f <br /> DC&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 ING AND A FINAL INSPE T N. L <br /> SIGNED �c,Z _ TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE y—��_ <br /> ADDITIONAL COMMENTS: 7� <br /> ,mak PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE 1 INSPECTION BYAa 2M <br /> DATE i <br /> IF <br /> E H 1426 Rev. - I-74 4 ' ' 7 Ga - <br />