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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOhrOFFICE 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 <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 Phone <br /> Address _ �d'S� G ,TU_. - City ?�/ys <br /> j <br /> Contractor's'Name License # 6/ a2y Phone3 <br /> xc <br /> TYPE OF WORK (Check): NEW WELL' DEEPEN/7 RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION/' PUMP REPAIR 17 PUMP REPLACEMENT 17 <br /> Other i-1 <br /> DISTANCE TO DEAREST: 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 /> In ustrial E --Eab-le Tool Dia. of Well Excavation <br /> omestic/private Dxilled Dia. of Well Casing1 <br /> Domestic/public Driven Gauge of Casing /Q <br /> irrigation Giavel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal M_ Other Other Information <br /> Geophysical' Surface Seal. Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: j—/ State Work Done <br /> PUMP '.REPAIR: /% State Work Done <br /> ES-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 Save 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 /> informatio4 is true to the-best-of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO 0 G AND A FINAL INSPECTION. �—r- <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: "'— <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE 9 - '] INSPECTION BY DATE <br /> ^E H 1426 Rev. 1-74 <br /> 1-742 �� <br />