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earn SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOE OFFICE SE: % 1601 E. Hazelton Ave. , Stockton, Calif. <br />'f 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 3=/ <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 therwork 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 X.a CENSUS TRACT <br /> Owner's Name ad �a-rro'4 G,[,f„fes-�� -- _-- Phone <br /> Address P k, City S <br /> Contractor's Name ® License #/jA?y4--?hone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN /`/� RECONDITION / /... DESTRUCTION /� <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT <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 u <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: T <br /> PUMP INSTALLATION: Contractor- 4,. , <br /> Type of Pump s Am. r H.P. / <br /> PUMP REPLACEMENT: / / State Work Done I Int 0. ; ,�, <br /> PUMP .REPAIR: / / 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 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 FI _ CTyION <br /> SIGNED _5 - F TITLE <br /> D W..PL T PLAN 'ON R E SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE'0 A <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE 1,11 FNAL INSPECTI N L <br /> INSPECTION BY DATE INSPECTION BY DATE ”? <br /> E H 1426 . Rev. 1-74 :r3�76 1 <br />