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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ,;FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. 7 7 W <br /> Telephone :: <br /> p {209) 466-6781 7 7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued J <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 here#in 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 Distract. <br /> JOB ADDRESS/LOCATION �j �i� a CENSUS TRACT <br /> Owner's Name ! k ��< Q� - lam(, Phone - Z <br /> Address Cit <br /> y��!i` �+ <br /> k. <br /> Contractor's Name License 04�i< �`'Q Phone <br />{ <br /> � � Y� <br /> TYPE OF- WORK (Check) : NEW'WELL / / DEEPEN /RECONDITION /� DESTRUCTION /-7 <br /> PUMP INSTALLATION PUMP REPAIR '/—/ PUMP REPLACEMENT <br /> .Other /-/ ,. <br /> DISTANCE TO NEAREST: ° SEPTIC TANK SEWER LINES PIT PRIVY <br /> ` SEWAGEIDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL'— PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial—- l Cable Tool Dia. of Well Excavation <br /> ,,d�Domestic/private t Drilled-- -—Dia-of Well Casing <br /> Domestic/public i Driven Gauge of Casing <br /> Irrigation ! i Gravel Pack Depth of Grout Seal <br /> Cathodic Protection� I <br /> I Rotary Type of Grout <br /> Disposal l Other. Other Informa_tion ' , <br /> —Geophysical tSurf ace :S <br /> . _ eal Installed By: <br /> PUMP INSTALLATION:• Contractor �j' ( j' �+ <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / 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 v;ell 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 AN FINAL 3IN ECT TON. \ I <br /> SIGNED TITLE <br /> I (DRAW PLOT PLAN ON REVERSE SIDE T_ <br /> I FOR DEPARTMENT USE ONLY <br /> PHASE I f <br /> APPLICATION ACCEPTED BY -.-_ DATE_'_ _ <br /> ADDITIONAL COMMENTS: f <br /> PHASE II GROUT INVECTION PHA IIF AL INSPECTIO <br /> IN ECT.ION..BY _. <br /> ....-._.....-DATE '_.. _ ,_ _.. _..� ... INSPECTION BY <br /> E H 1426 Rev. 1=74 ". F b 1117.7 <br />