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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFir FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif, <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ._D <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued .�/-7 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local S-Iealth 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 Regulat ons of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION12 !, CENSUS TRACT <br /> Owner's Name Prone <br /> Address . , .. q V- k _.'t i,J. rt <br /> , 427City <br /> Contractor's Name License # 19 7_2=1,7,P .6 746 <br /> TYPE OF WORK (Check): NEW WELL/? DEEPEN 47 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION E/_ PUMP REPAIR �R/ PUMP REPLACEMENT /_7 <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 <br /> _- Domestic/public Driven Gauge of Casing � I <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout s ` <br /> Disposal Other Other Information <br /> Geophysical Surface.-.Seal Installed By <br /> PUMP INSTALLATION: Contractor <br /> Type of_Pump H.P. / 717,7 <br /> PUMP REPLACEMENT: %/ State Work Done <br /> PUMP 'REPAIR: State Work Done ) <br /> ES•TRUCTION 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 kno edge a_ belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO UTING <br /> 2—A FIN P N <br /> STGNE TLE <br /> D P OT PLAN ON �RSE SIDE <br /> OR DEPAR T USE ONLY <br /> PHASE I 14 <br /> Q / 7 <br /> APPLICATION ACCEPTED BY DATE ! —b <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE L1j#FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYZZ, ATE -A <br /> j^ V` <br /> it E H 1426 Rev. ]-7 4 1-7*4b ' <br />