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SAN JOAQUIN LOCAL HEALTH DISTRICT �i1L <br /> FOE OFFICE 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 l 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 O T CENSUS TRACT <br /> Owner's NameC Owl I-�- z yjg <br /> Phone <br /> Address �Q E r &Lkpj City STD eg rp <br /> r ' z•s <br /> Contractor's Name E�,. 6 *License �� Phone <br /> 1 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /—/ RECONDITION /_7 DESTRUCTION /_ } <br /> PUMP INST LATION / / PUMP REPAIR 17 PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES PIT PRIVY <br /> SEWAGE DISPOS 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 I- <br /> Domestic/public Driven Gauge of Casing 010 <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: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT": / / ;State Work Done <br /> PUMP .REPAIR: /7. 7 ;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 reguiating`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 themesbefore-putting the- well in use. The above <br /> information is true to the best of my, pr and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO OUTING A FIN INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHAS I GROUT INSPECTION PHASE <br /> /F AL INSPECTIO <br /> INSPECTION BY 2-U/ DATE INSPECTION BY DATE 7- <br /> E H 1426 Rev. 1-74 1/77 2M <br />