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r - - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOH OFFICE USE: Jx� 1641 E. Hazelton Ave. , Stockton, Calif, <br /> Telephone : (209) 466-6781 ` <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued3'l.S -70 I <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 E CENSUS TRACT <br /> Owner's Name (� Phone 4 <br /> Address —??). � <br /> City � 1<70W,-- <br /> Contractor's Name RK WELL, 4iPhone <br /> L1 IW License �� � A-7—SnI <br /> ILI <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN/ / RECONDITION /�. DESTRUCTION /_ <br /> i PUMP IN S1 <br /> LATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / '^ �-� <br /> DISTANCE TO'NEAREST: SEPTIC TANKSEWER 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 /> dustrial Cable Tool Dia, of Well '.Excavation 1641 <br /> Domestic/private Drilled Dia. of Well Casing ' <br /> Domestic/public Driven Gauge of Casing L <br /> Irrigation avel Pack Depth of Grout Seal _ / <br /> Cathodic Protection Rotary Type of Grout ' <br /> Disposal - Other Other Information" <br /> Geophysical Surface Seal Installed By: <br /> s <br /> PUMP INSTALLATION: Contractor <br /> ? Type of Pump H.P. <br /> PUMP REPLACEMENT: _ <br /> / / State Work Done <br /> f <br /> PUMP .REPAIR: <br /> / / State, Work Done 1 <br /> DESTRUCTION PF WELL: Well Diameter Approximate Depth <br /> Describe Material an, 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 pertainingrto 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 DRILLER S 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 AiGROUT INSPECTION <br />'RIOR TO GR§RkTING AMQ AN SPE N. <br /> SIGNED TITLE S ;I <br /> (DRAW PLOT FLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _ k DATE rJ' K7 <br /> ADDITIONAL COMMENTS: s <br /> , PHASE II GROUT INSPECTION PWEhjjjjFINAL INSPECTION <br /> rNq, <br /> SPECTION BY <br /> D E INS; ' u <br /> CYTON BY ti DATE `� <br /> �.QQ� <br /> E`H 1426 Rev. 1-74 11177 2M � <br />