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'. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ' FOR.,QFFIGE 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 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is h'e y 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 Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations •of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION t ( !t CENSUS TRACT �-- <br /> Owner's Name --re)A^, Phone <br /> Address a 4(y 4 C YIELD City sLDGgTO K) <br /> Contractor's NameG }(.W A t�1�_ .)Q.Itir( dV&- _ C� . .License # &)161S2-Phone 632-793--), <br /> TYPE OF WORK (Check) : NEW WELL /N DEEPEN / / RECONDITION /-7 DESTRUCTION /-7 <br /> . PUMP INSTALLATION / / PUMP REPAIR / / 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 ')C Drilled Dia, of Well Casing <br /> t Domestic/public Drigen ,.. � Gauge of Casing1b.0 pvc <br /> Irrigation ""-X7 Grav'el'"'Pack-'-'-. -pepth-of"'Grout""Seal` ;:yo C <br /> Cathodic Protection ��� Rotary Type o.f._Grout� ��_To N L'Tg_ <br /> Disposal Other Other,._I.nformatio_n - � <br /> Geophysical # Surface Seal Installed B 12 <br /> ' PUMP INSTALLATION: . Contractor 1 <br /> Type of Pump ^ar, H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> r PUMP .REPAIR: / / State Work Done <br /> {.DES•TRUCTION 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 /> Viand the State of California pertaining to or regulating well "construction. Within FIFTEEN DAIS <br /> 'rafter 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 GROUTI AND WIN SPECTION. <br /> ,SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 6 _2_2 <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 7426 Rev. 1-74 �1 _,.. _ _ : 117.7 _. 2M <br />