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jSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO£�'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> - <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. - S/ <br /> THIS PERMIT EXPIRES 1 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 ancL Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION /G/7�iy/p US CENSUS TRACT <br /> Owner's Name &Ifl,41 L RPhone 3yly- " `_ <br /> Address 1 3 23 -IVvI_L��Jpo%EF_ L- G/ - City , <br /> Contractor's Name f/_ / iQC�_//YE S, �,, �a License Phone ��� ye943 <br /> TYPE OF WORK (Check): NEW WELL -/_7 DEEPEN /_7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR -10 PUMP REPLACEMENT f7 <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 We11'Excavation C14 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <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: State Work Done 4 Q, <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 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 A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FIM I PECIION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 62-3-22- <br /> ADDITIONAL COMMENTS: ' <br /> PHASE II GROUT INSPECTION '--PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY -� DATE <br /> E H 1426 � ' __fit 25 2M <br /> -;'Aev. �.-7 4 - '�- --- <br />