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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO AFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.,z-0-�- <br /> THIS PERMIT EXPIRES I YEAR FROM DATE 'ISSUED Date Issued <br /> (Complete In Triplicate) <br />.Application is hereby made tolthe 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 /> tCounty Ordinance No. 1862 and1the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner'a Name d `1. ,� k <br /> Phone '0��ff <br /> Address d � ,_...,. _ _ r <br /> City <br /> Contractorts Name License # Phone <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN '/'? RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION ,El PUMP REPAIR -/_7 PUMP REPLACEMENT /-7 <br /> Other <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES FIT 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 t� <br /> Industrial t Cable Tool Dia. of Well Excavation <br /> Domestic/private i Drilled Dia. of Well Casing <br /> Domestic/public A Driven Gauge of Casing <br /> Irrigation i Gravel Pack Depth of Grout Seal ;` <br /> Cathodic Protection i Rotary Type of Grout ' <br /> Disposal _. t Other Other Information <br /> Geophysical <br /> Surface Seal Installed B : <br /> PUMP INSTALLATION <br /> - Contractor <br /> Type of <br /> Pump - R.P. <br /> PUMP REPLACEMENT: ' State Work Done - <br /> PUMP 'REPAIR: _ / / -State Work Done <br /> ' I <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth i <br /> ✓_ _ <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 r <br /> i_ y putting-the..we11 in.use.... ,The above � <br /> information is true to the•besi of my knowledge and belief. I WILL .CALL -FOR'A 'GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL ;INSPECTION. <br /> SIGNER TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> i FOR DEPARTMENT USE ONLY <br /> PHASE I t. <br /> 5 <br /> APPLICATION' ACCEPTED BYDATE 'q 14 ',?,C <br /> ADDITIONAL COMMENTS: ;i , t <br /> PHASE II GROUT INSPECTION PHASE II1 FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYDATE <br /> E H 1426 Rev. 1-74� h/75 •2M <br />