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SAN JOAQUIN FOCAL HEALTH DISTRICT -- <br /> t FO$rOFFICE USE: 1601 E. .Hazelton Ave: , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> rf THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby wade 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 /> ,TOB ADDRESS/LOCATION CENSUS TRACT <br /> � <br /> Owner's NameAt4r Lft""--a <br /> 6 Phone �46 <br /> I <br /> Address City <br /> Contractor's Name License # -f-h—one ��- Z,!5 <br /> TYPE OF WORK (Check): NEW WELL /-7 DEEPEN '/-7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION REPAIR /-7-pump REPLACEMENTr7 <br /> Other <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 � <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing p <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 GeophysicalSurfaceSurface Seal Installed By: <br /> PUMP INSTALLATION: Contractor =0 �, <br /> Type of Pump H.P. 70 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP "0§P*Rt:---- State Work Done <br /> ESTRUCTZON OF WELL: Well Diameter <br /> 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 GR ANDAFINAI—INSPEIMI". S� <br /> SIGNED .tLPA-J�? T <br /> (DRAW L0 PLAN ON REVERSE E <br /> DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY / DATE <br /> ADDITIONAL COMMENTS <br /> PHASE II GROUT INSPECTION PHA I;11VINAL INSPECTI <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> t <br /> } E S 1.426 Rev. 1-74 <br />